VA nurse fails to visit patients, lists dead patient as 'stable'
by The Associated Press
published March 15, 2007 3:50 pm


Salisbury – A nurse responsible for monitoring care of frail military veterans didn't visit patients as required for two years and filed one report that listed a dead patient in stable condition, according to a federal inspection obtained by The Charlotte Observer.


Inspectors reviewed records last year of 10 seriously ill veterans at Hefner VA Medical Center who were housed in private nursing homes, five of which ''did not meet the minimum threshold standards for quality of care,'' according to a report issued in September by the VA Office of Inspector General.

The VA nurse was supposed to visit patients at least quarterly, but she failed to do so for more than two years and visited only on ''rare occasions'' when requested. Inspectors found some veterans had suffered ''significant weight loss,'' though the nurse's notes listed all patients as stable – including one man who had died 12 days earlier, the report said.

The nurse, who wasn't named in the report, is still employed by the hospital but is no longer responsible for nursing home visits, Hefner VA Medical Center spokeswoman Carol Waters said in an e-mail Wednesday to the newspaper.

Donald Moore, the hospital's director at the time, said he suspended the nurse and her supervisor. Moore said the case was among the most serious during his tenure, but that physicians thought the nurse was a good employee.

''It was poor charting. It wasn't as bad as it seems, though I know that sounds crazy,'' he said. ''The feedback on her was very positive. We had over 1,700 employees, and somebody will drop the ball.''

The care offered at VA medical centers have come under a microscope since revelations surfaced that Walter Reed Army Medical Center, one of the country's top military hospitals in Washington, D.C., provided inadequate outpatient care to troops injured in the Afghan and Iraq wars.

The Salisbury hospital is one of the fastest-growing VA hospitals in the country.

The Department of Veterans Affairs contracts with private nursing homes when its hospitals are full or cannot provide specialized long-term care needed by some veterans.

''The nurse wasn't doing what she was supposed to be doing, clearly, but she was having the nurses at the nursing home send her information,'' Christa Sisterhen, associate director at the VA office that did the investigation, said Wednesday.

A separate investigation in 2005 found a history of neglectful care at the hospital, according to a report by the Office of the Medical Inspector. That report determined doctors and nurses had cut corners on treatment, manipulated records, and didn't talk enough with patients and families. Investigators also determined two veterans who died at the hospital had received inadequate care.

Moore, who took over the hospital in June 2004, said he worked to change the quality of the medical staff and improve the hospital's reputation among veterans.

''We removed more physicians in the two-and-a-half years I was there than in the previous 30 years. We raised the bar,'' he said. ''Salisbury was a sleepy little place where people came to retire. We made it where marginal performers couldn't survive.''

Moore now heads the VA hospital in Phoenix.