HARMLESS ERROR

VETERAN

Am I a statistic or a “harmless error” of the Veterans Administration Health Care System?

The diagnosis was that I needed a triple bypass and an evaluation of my heart valve.

My heart surgery was put on the fast track and scheduled for late March, 2011. The result was a “successful” quadruple bypass and a bovine aortic valve replacement.

Beginning in mid-July of 2011, I started experiencing lower back pain on the left side. It became increasing more severe. I finally decided to go to the emergency room at McGuire Veterans Hospital located here in Richmond, Virginia. The ER doctor examined me, and her suspicion was an intestinal issue. I was treated and released.

McGuire VA MEDICAL CENTER

I was diagnosed six weeks later with an abscess between T-8 and T-9 vertebrae caused by the MRSA (Methicillin-resistant Staphylococcus aureus) bacteria that colonized in my spine. The abscess was putting pressure on the spinal nerves and needed to be removed. McGuire Veterans Medical Center performed a laminectomy on my spine, and I have not walked since the surgery.

Below is an excerpt from my progress notes dated 09/21/2011 on page 630:

Plan:
Epidural abscess & Back pain: The source is probably the bovine valve which was replaced on March [30th, 2011] since there is no other obvious cause of abscess in this otherwise healthy gentleman. No history of pneumonias or admissions for sepsis. No hx of IV drug use.

The progress note points the smoking gun back towards the “bovine valve” that was implanted at McGuire Veterans Medical Center five months earlier.

SITTER AND BARFOOT SIGN (4)

The Veterans Administration placed me in a veterans’ nursing home as a paraplegic, cast aside like waste, destined to die a slow and heartbreaking death—alone.

bc

DEBUNKING THE MYTH

OPINION:

VETERAN

There is no mechanism in place for the Department of Veteran Services to perform operational oversight of Sitter and Barfoot Veterans Care Center, according to the Care Center’s administrator.

Sitter and Barfoot is a long-term care facility that provides rehabilitation services and medical care and comfort to as many as 160 veterans. It has two units, each with sixty private rooms. In addition, there is a specialized Alzheimer’s/dementia wing with forty rooms.

SITTER AND BARFOOT EDITED FRONT

I requested a copy of an inspection done by the Department of Veteran Services. Instead, I was shown the review done by the Department of Veterans Affairs, the federal agency. When questioned, the administrator stated that the Virginia Department of Veteran Services does not inspect the operation of Sitter Barfoot. Further, the administrator said that Sitter and Barfoot is checked twice a year by two separate agencies: one federal and one state.

The two annual inspections, done by the Virginia Department of Health and the Department of Veterans Affairs, are done to evaluate the operation and care given to the most deserving of our aging population.

The Department of Health and Department of Veterans Affairs inspections cover the operation of the Care Center and typically last three to four days. Each department operates independently and comes at different times of the year.

The Department of Health evaluates the overall care delivered to those 160 veterans: quality of care, medical records, privacy, personnel practices; rehabilitation, food preparation, staffing, resident complaints, medications and more. Towards the end of the inspection process, a meeting is scheduled. The administrator and the director of nursing convene with the survey team to review the deficiencies found and draw up a corrective action plan.

Sitter and Barfoot received the highest grade possible in the 2014 survey.

After an interview with a health department surveyor, the health department failed to address four of my concerns:

• Medication errors
• Short staffing
• Ignoring communications
• Lack of dignity and respect

The health department showed little interest in my issues. Complaints from nursing home residents are considered unreliable and often ignored.

It begs to question the effectiveness of such an assessment and the trustworthiness of the Department of Health.

The Department of Health acknowledges a 12 to 15 month wait time to investigate complaints. I now have to wait again to get resolution. Residents in a nursing home would be fortunate to have that many months left.

The cleanliness of Sitter and Barfoot affects those doing the survey and accounts for the disparity between fiction and reality. Cleanliness covers many evils. Overall appearance diverts attention and unduly influences the outcome of the inspection.

The Health Department and Sitter and Barfoot are both state agencies. I question the reliability of one state agency evaluating the performance of another. Corruption, complacency, and a lack of transparency obscure objectivity in government self-appraisals. It is unlikely that a state agency tarnishes another agency’s operation; particularly one with such high and honorable intentions as caring for aging veterans.

The Department of Veterans Services needs more accountability in the delivery of care to deserving veterans.

Accountability does not stop with the administrator. The administrator has self-interests and financial demands to protect, as well as job security for the employees that have shown allegiance. The administrator and staff can hardly be expected to be objective. Government agencies have demonstrated that they do whatever is necessary to protect their province.

The Department of Veterans Services needs to be held accountable and responsive to the needs of all veterans it serves. It is mandatory that the Department of Veterans Services be pro-active and aggressive in ferreting out problems. Not just a self-serving propaganda arm for the Commonwealth.

Accountability at the top will cure the ills of Sitter and Barfoot and the Department of Veterans Services—and accountability with consequences must filter down to all levels.

bc