“Deficiencies in care” at a Veterans Affairs-operated nursing home in Batavia may have caused a resident to suffer a “preventable decline in health” that ultimately led to their death, a report from the VA’s Office of the Inspector General found.
The report is the latest blow to an embattled VA system. A 54-page OIG report from September found that patients with serious health conditions in the local VA system waited months to get treated.
Weeks before that September report was made public, then-WNY VA Executive Director Michael Swartz and then-Chief of Staff Dr. Philippe Jaoude were reassigned to non-patient facing roles, according to The Buffalo News. Four of the five members of the local VA system’s leadership team are currently serving in acting capacities, according to the system’s website.
Staff at the Batavia Community Living Center mismanaged the resident’s dementia and diabetes, the report found. Much of the mismanagement stemmed from healthcare workers’ failure to properly document the resident’s medication and nutritional intake.
That mismanagement contributed to that resident’s placement in hospice care last year, where they died after two days. The resident was in their 70s.
The report identified another case where medical staff took six days to intervene when a resident in their 80s all but stopped eating solid food. That resident had to be transferred to the emergency room twice.
The OIG report offered 10 recommendations to VA Western New York Health Care System Interim Director Harold Pharis. The recommendations mostly instruct Pharis to provide education to system employees and ensure that staff follow policies and requirements.
Pharis concurred with all 10 recommendations. Some target dates for implementation of the recommendations have already passed, others are set for November and December.
A spokesperson for the local VA system did not immediately respond to a request for comment on Sunday.
Rep. Tim Kennedy, a Democrat from Western New York and a member of the House Committee on Veterans Affairs, said in a statement that he was “appalled” by the “devastating failures” identified in the OIG report. Kennedy demanded a “full review of these issues.”
“The report’s findings... indicate a systemic breakdown that puts our veterans at risk,” Kennedy said. “Most troublingly, these actions occurred prior to the Trump Administration’s mass layoffs at the VA, which could potentially further exacerbate the situation and put current and future Batavia residents at risk.”