Memphis’ Veterans Scandal

Although very little of the veterans affairs scandal has been pursued by Memphis media, we are involved in it, too.

Last night on the Kelly Files, Meagan Kelly interviewed Rep. Jeff Miller (R-Fl). She characterized him as one who early on sounded alarms about the state of our veterans’ health care. She mentioned that he had found deaths in South Carolina; Augusta, Ga.; and Memphis.

From what you read currently, you’d think it hadn’t affected us. A little googling proves otherwise.

Patrick Howley of the Daily Caller reported on October 24, 2013:

The Obama administration’s Department of Veterans Affairs (VA) oversaw three preventable veteran deaths due to errors and negligence at a VA hospital in Memphis, according to a new VA Office of Inspector General (OIG) report and other documents obtained by The Daily Caller.

The damning OIG report comes just weeks after VA admitted that six veteran deaths were linked to delayed cancer screenings at a VA facility in South Carolina and a report that appointment delays led to veterans being harmed in Augusta, Ga. VA, which spent more than $3.5 million on furniture on the last day of fiscal year 2013, also awarded a five-figure bonus to the executive who oversaw the Memphis facility, even as it acknowledged that problems were cropping up.

Memphis VA Medical Center saw three patient deaths in its emergency department that prompted an anonymous phone call to the OIG in October 2012.

In January 2013, the OIG found that “Facility response [to the deaths] considered inadequate” and a review was initiated with a May 29-31 site visit.

“We substantiated that a patient was administered a medication in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately 5 hours after presenting to the ED,” according to the OIG report’s conclusions.

In each case, erroneous actions by hospital staff contributed to patient deaths, according to the OIG report.

This was not the first time that the Memphis emergency room came under scrutiny.

“We previously inspected the facility’s ED in 2012, after a confidential complainant alleged that delays and conditions in the ED were putting patients at risk. … The facility is still in the process of taking follow-up actions,” according to the report.

The Memphis hospital’s problems have been considered severe for quite some time.

The reporter said the Memphis VA did not respond to his queries.

Miller himself wrote about it in his newsletter:

An October 23 report by VA’s Inspector General documented three preventable veteran deaths at the Memphis, Tennessee, VAMC. Like other hospital systems, VA isn’t immune from human error – even fatal human error. But what the department does seem to be immune from is meaningful accountability. Given that these tragic events are part of a pattern of preventable veteran deaths and other patient-safety issues at VA hospitals around the country, it’s well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible. It’s the only way to ensure veterans get the medical care they deserve and prevent heartbreaking events like this from happening in the future. Until VA leaders make a serious attempt to address the department’s widespread and systemic lack of accountability, I fear we’ll only see more of these lapses in care.

His words proved prophetic as now these disasters are cropping up across the nation.

The Washington Free Beacon provided more information:

One patient—who, like all three examined in the report, was not named—checked into the Memphis facility with a “non-urgent” condition.

A nurse noted in the facility’s electronic health record (EHR) system that the patient was allergic to aspirin. A physician subsequently ordered and administered a drug known to cause a reaction in patients with aspirin allergies.

“The physician’s order … was hand-written rather than being entered into the EHR as required by local policy,” the IG noted. “Entering the order electronically would have generated an alert that the medication was contraindicated due to the patient’s drug allergy.

The patient went into cardiac arrest an hour later. The patient died eight days later after the family opted to end life support.

Another patient was given a high dose of narcotics to ease extreme back pain. A nurse administered the drugs and left. Less than an hour later the patient was found unresponsive. He was resuscitated but entered a coma and died 13 days later.

An internal review noted that equipment designed to monitor the patient’s vital signs stopped reporting data five minutes after the nurse left the room. But the IG also noted that hospital staff were not “within hearing range” of the alert system, and “it was not connected to a centralized monitoring system.”

A third Memphis patient, who had “a history of frequent hospitalizations and complex medical issues,” was admitted after complaining about shortness of breath and eye pain.

An hour after being admitted, according to the IG, the patient reported being confused. That fact was never reported to the attending physician. The patient was subsequently found unresponsive and died the following day.

“His deterioration may have been prevented if appropriate antihypertensive medications had been given more aggressively,” the IG found.

Internal investigations of the two doctors involved in the three incidents cleared them of wrongdoing.

A statement from the VA said it has already taken a number of steps to address the issues raised by the report.

Reported problems in Memphis actually began in August 2011, when the IG received reports that patients were often left waiting in hallways on stretchers before being admitted.

James Robinson, then the director of the Memphis hospital, received a performance bonus of more than $10,000 for fiscal year 2011.

That’s Washington for you. Do your job poorly and you’ll still be rewarded.

You’d think these cases would be revisited by the local media since all this came up.

But then again, you’d think the Commander in Chief would give a damn about his veterans.

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