Calling it a case of “mission delayed turning into mission failure,” American Legion National Commander Brett P. Reistad called for VA officials to implement a plan to prevent future communication breakdowns between home-care social workers and VA medical centers.
Reistad specifically referred to the case of a veteran who had to undergo a partial leg amputation due to delays in receiving home health consultations after being discharged from the Richard L. Roudebush VA Medical Center in Indianapolis. The patient, who was treated for diabetic ketoacidosis and an ulcerated foot abscess, “did not receive the necessary home health care,” according to U.S. Special Counsel Henry J. Kerner.
The patient required frequent changes to his wound dressings. As a result of the veteran not receiving the necessary care, an infection occurred which later required a below-the-knee amputation. Investigators determined that social workers were directed to stop entering home health care consults into the Computerized Patient Record System due to a lack of training.
“The U.S. Office of Special Counsel assured the president that VA has taken the necessary steps to prevent similar problems in the future,” Reistad said. “The American Legion certainly hopes that those assurances are well-founded. Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice.
"We thank the whistleblowers who helped expose this case. It reinforces why The American Legion supported legislation that protects these brave employees. The American Legion believes in VA. It’s why The American Legion visits VA medical facilities across the country as part of our System Worth Saving program, so we can identify critical needs and share best practices. We will certainly review this latest incident again as part of our SWS agenda. We also believe that recent reforms such as the Mission Act and increased accountability will improve an already-strong VA system. That said, tragedies such as what happened in Indianapolis should never occur. We expect VA to learn from this and act accordingly.”