WASHINGTON — The veterans hospital in Columbia is changing some of its patient-care procedures after a federal investigation prompted by the death of an elderly patient from a bacterial infection.
The lapses at Dorn VA Medical Center did not cause or likely contribute to the 93-year-old’s death after a six-day stay last September, but they require correction, according to the May 31 report by the VA’s Office of the Inspector General.
Among the problems cited at the Garners Ferry Road hospital were nurse understaffing, unreliable meal delivery, lack of nutritional counseling and communications breakdowns among medical staff.
Evetta Gregg, a Dorn spokeswoman, said leaders of the 170-bed medical center cooperated with the VA probe. “Identified concerns are viewed as opportunities to improve the services we provide for our veterans and to enhance education for our staff,” she said.
The VA inquiry included examining medical records along with phone and personal interviews of Dorn director Rebecca Wiley and doctors, nurses and other hospital employees. The VA dispatched investigators to Dorn for a day of meetings on Feb. 14 after the deceased’s daughter filed complaints with the federal agency and with the office of U.S. Sen. Lindsey Graham.
Neither the man who passed away while in Dorn’s care nor his daughter was identified in the VA inspector general’s report.
Aides to Graham said they could not say whether the Seneca Republican had intervened on behalf of his constituent because she wasn’t identified and the senator’s office gets numerous requests for help from veterans or their family members.
Dorn is one of two full-fledged veterans hospitals in South Carolina, along with Johnson VA Medical Center in Charleston. The agency also runs clinics and veterans centers in Myrtle Beach, Rock Hill, Beaufort and other locations in the state.
While the VA probe of Dorn focused only on one patient, its findings shed light on the difficulties in providing health care to South Carolina’s 410,000 veterans, many aging.
The VA investigators concluded Dorn medical personnel tried to respond to the concerns of the daughter, who maintained a bedside vigil near her ailing father after he had been placed in an isolation room because his infection was highly contagious.
“We found that nursing and physician staff interacted with the patient’s daughter on a daily basis and that staff made efforts to address the daughter’s concerns as they arose,” the report said. “However, we are unable to assess the quality of staff communications with the daughter or whether satisfactory, corrective actions were taken.”
After the report was concluded, Dorn director Wiley accepted its findings and said changes were being made to address concerns.
One of the daughter’s nine complaints was that her father, who had a history of Parkinson’s disease and heart ailments, had an “inadequate and inappropriate oral diet” at the hospital, instead of intravenous nutrition.
The VA investigators found the father didn’t qualify for IV nutrition because he had a functioning digestive system. They said, however, that two trays of food were left outside his room but not brought inside due to a communications breakdown among medical aides. Dorn has changed its procedures and “now requires nursing assistants to follow the meal delivery cart and deliver trays directly to patients, including those in isolation precautions,” the VA report said.
On the fourth day of his stay, the daughter asked for help transferring her father to a private hospital, but Dorn officials refused to pay and said such a move would be risky.
“The daughter was told that she could take her father to the private-sector hospital, but she would have to sign him out against medical advice,” VA investigators wrote. “While we believe that staff followed procedures, the daughter was nonetheless frustrated with what she perceived as an overall lack of helpfulness on the part of the facility staff.”