Report: Veteran's leg amputated after VA fails to log home care appointments

A veteran treated at an Indianapolis-based Department of Veterans Affairs Medical Center had part of his leg amputated as a result of the hospital's mismanagement of home healthcare records, Task & Purpose reports.

The patient experienced a "significant" delay in follow-up care after being discharged from Richard L. Roudebush VA Medical Center in June 2017 following treatment for diabetic ketoacidosis and an ulcerated foot abscess, according to an April 10 U.S. Office of Special Counsel letter addressed to President Donald Trump. The veteran was supposed to have a home healthcare consult for assistance dressing his foot wound, but the consult was never properly processed in the VA's computerized patient record system. Due to the lack of follow-up care, the patient developed a wound infection that required a below-the-knee amputation.

Three medical center whistleblowers alerted the special counsel that social work service managers at Richard L. Roudebush VA Medical Center directed their social workers to stop recording details on home healthcare appointments in the EHR, according to the report. The managers said the action was "outside of the social workers' scope of practice," and the change was implemented without collaboration between services departments.  

"We found this decision led to a system breakdown, as the transition was not implemented with key services in a collaborative and cohesive manner, allowing time for coordination and education," VA Secretary Robert Wilkie wrote in an Aug. 13, 2018 letter on the incident, Task & Purpose reports. "Second, the lack of adequate planning, training, and communication resulted in a significant delay in at least one veteran's case with potential harm for others."

After completion of the Special Counsel's report, the medical center updated and implemented standard operating procedures for home healthcare consults, including post-discharge follow-ups and monitoring consults. Staff members have been trained on the new procedures, and social workers can enter home healthcare consults in the EHR. Additionally, referral nurses are now required to immediately contact the provider or social worker to address any incomplete home healthcare consults, rather than discontinuing any incomplete reports.

An external peer review of the veteran's case is currently underway, according to the report.

To access the Special Counsel's letter, click here.

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