The Office of the Inspector General has found significant “deficiencies’ ‘ in the care of a patient who died at the Charlie Norwood VA Medical Center after receiving care at the facility.
The May 12 report found that doctors and nurses at the VA failed to provide the correct preoperative care for the patient, who suffered from a variety of ailments including hypertension and alcoholism.
In 2020, the unnamed patient was to undergo urologic surgery, which the Inspector General notes is a minimally invasive procedure. However, in preoperative testing, the patient showed symptoms of “orthostatic hypertension and physical deconditioning.” The report states that the preoperative patient also showed the signs of alcohol withdrawal.
The patient died 13 days later in hospice following the surgical procedure.
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The report says that the patient’s primary care physician had noticed abnormal chest scan images and recommended a barium swallow test, a bone density test and more CT scans. Despite the fact that some of the tests were ordered four months before the scheduled surgery, records show that the VA never completed the tests and instead gave the patient antibiotics and cough syrup.
“Faculty staff provided conflicting explanations for this failure and were unable to provide evidence to explain why this test wasn’t ordered. The provider never ordered a bone density test,” the report states.
Furthermore, the report states that the patient suffered dramatic weight loss in the months preceding the surgery, but the VA responded by ordering more blood tests, offered nutritional advice and suggested the patient stay hydrated with sports drinks.
Two days before the surgery, the patient complained of being weak and “not able to keep anything down;” however, the records show the patient was not scheduled a same day appointment or instructed to report to the emergency room.
At some point during the preoperative care, it was discovered the patient was suffering from alcohol withdrawal, and the hospital’s protocol regarding such withdrawals was initially followed with the patient being given benzodiazapines, which quell the withdrawal symptoms, upon being admitted to the hospital.
However, with no explanation, the alcohol withdrawal protocol was stopped prior to surgery and the drug treatment was reduced to “as needed.”
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After surgery, a physical therapist reported the patient as being confused and disoriented. The medical staff then placed the patient in what is known as the Trendelenburg Position, which lowers the patient’s head and elevates their feet.
While, it appears the ordering of the position, which rushes blood to the head, was not noted on the patient’s chart, at least one nurse testified the patient was placed in that position to prevent them from trying to get out of the bed. The Office of Inspector General was not able to determine for what length of time the patient was kept in this unnatural position.
The Office of the Inspector general concluded its report with a 35-page action plan for the hospital to follow.
This latest report is the fourth investigation conducted at the Charlie Norwood VA since 2019.
A message to a VA spokesperson was not returned Tuesday.
Scott Hudson is the senior reporter for The Augusta Press. Reach him at scott@theaugustapress.com
