VA Report: Mismanagement of patient care at Tomah VA contributed to death

The 30-year old patient died in April of 2019. The VA's Office of Inspector General released the results of it's investigation on August 26th, 2021

TOMAH, Wis. (WKBT)- A Department of Veterans Affairs report finds doctors and nurses at the Tomah VA mismanaged care of a patient, contributing to that patient’s death at another VA facility.

The 30-year old patient died in April of 2019. The VA’s Office of Inspector General released its investigation on August 26, 2021.

According to the report, the veteran walked into the Tomah VA’s urgent care department and told staff they had a seizure. There was no alcohol in the patient’s blood, but the patient told staff they typically drank half a liter of vodka a day. The patient was admitted for immediate care, but their condition continued to deteriorate.

Over the next month, the patient was transferred to two other facilities before being admitted to a hospice unit at a different VA facility, where they died.

Congressman Ron Kind asked the Office of Inspector General to investigate. The OIG report found Tomah VA “physicians did not address the patient’s abnormal electrocardiogram
and did not prescribe an adequate medication regimen to address the patient’s delirium tremens effectively.

Nursing staff did not complete all required Clinical Institute Withdrawal Assessment for Alcohol  scales.2.  Further, a physician improperly ordered the patient’s restraints and nursing staff failed to obtain the patient’s full vital signs while the patient was in restraints.” READ the full report here.

The Tomah VA released this statement to News 8 Now:

” VA extends its sincere condolences to the family of this veteran and takes this loss personally. While the April 2019 incident doesn’t represent the quality health care our Tomah VA medical center professionals provide daily, the OIG team did find opportunities and provided recommendations for improvement.

It’s important to note that the OIG report did not address the veteran’s entire course of care. Without a comprehensive review, attributing the veterans clinical deterioration to Tomah VAMC is inconclusive

Wisconsin Sen. Tammy Baldwin shared this: “I’m deeply saddened by this tragic loss of life and I’m concerned by the OIG’s findings. I appreciate the Inspector General’s diligence, and the thoroughness of their investigation.  I will be following up with both the Tomah VA hospital and VISN 12 leadership requesting to be updated on their implementation of the IG’s recommendations.”

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