A botched change in the way
home-care visits were scheduled for patients released from the Veterans Affairs
Medical Center in Indianapolis resulted in a veteran losing part of his leg,
according to a copy of an investigative report and letter to the president.
The letter to President Donald
Trump said a Department of Veterans Affairs investigation prompted by three
whistle-blower complaints revealed "a system breakdown because leadership
attempted to implement the change without collaborating with key services or
allowing time for coordination and education." The letter is from Henry J.
Kerner of the U.S. Office of Special Counsel, an independent federal agency
that looks at whistleblower disclosures and helps protect them from
retaliation.
That breakdown resulted in delays
in the care of veterans, the investigation found, including one man discharged
from the Indianapolis medical center in 2017 after receiving treatment for
diabetic ketoacidosis and an ulcerated foot abscess. Because of delays
attributed to the new process, the letter said, "the veteran did not
receive the necessary home health care."
The letter explained the VA investigation
determined the man's wound "became infected and required below-the knee
amputation due to the delay in receiving dressing changes" from a home
health care provider.
“It is unconscionable that after serving his
country, a veteran lost his limb not on the battlefield, but because of
mistakes made by the agency entrusted to take care of him," said Special
Counsel Kerner. "While I commend the VA for taking the necessary steps to
prevent similar problems from occurring in the future, this situation should
never have happened.”
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