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Government, Politics & Issues

Newest Cochran evaluation finds more monitoring, oversight problems

This aticle first appeared in the St. Louis Beacon, June 12, 2012 - WASHINGTON -- U.S. Sen. Roy Blunt, R-Mo., said Wednesday that he was upset by the lack of significant response by the Veterans Affairs Department to continuing reports of problems at the John Cochran VA medical center in St. Louis – including a patient death after dialysis treatment that inspectors believe showed inadequate nursing care and leadership.

“I’m aggravated about the way this facility is being run,” Blunt told reporters, saying he still had not received a response to a letter about Cochran that he sent to the VA Secretary Eric Shinseki on April 12. “I’d like to see them get serious and I’d like to see them tell the truth,” Blunt said. “There are still big problems.”

After an April report on persistent problems with the pre-cleaning and treatment of dental instruments (see below), the VA inspector general reported June 11 on hemodialysis nursing care.

Inspectors found that a licensed practical nurse (LPN) “did not recognize and report changes in the condition” of a dialysis patient who was unconscious at the end of his treatment in December 2010. The patient got emergency medical attention but died the next day.

The report found “a lack of effective nursing leadership” in the dialysis unit. “Staff competencies were not completed, RN and LPN roles were not delineated, charge nurse responsibilities were not defined, and there was no policy for reporting events to the charge RN or physician.”

Inspectors said the dialysis unit’s staff “perceived that they suffered retaliation when they reported complaints” against the specific LPN. The unit’s nursing leadership failed to take “disciplinary action for the one individual,” even though state nursing regulations and local policy indicate that LPNs “cannot perform independent initial nursing assessments.”

Read the Beacon’s earlier story below.

WASHINGTON – The controversy over the cleaning and treatment of dental instruments at the John Cochran VA Medical Center in St. Louis took another turn Monday with the release of an inspection report that cited some progress but also found continued problems with monitoring and oversight.

The “follow up evaluation” by the VA’s inspector general examined whether Cochran had fully responded to the recommendations of a 2011 report that found that the proper reprocessing of reusable dental instruments had been a long-standing problem there.

The new inspector general’s evaluation, dated April 5 but released this week, concluded that:

  • St. Louis VA Medical Center’s committee on reusable medical equipment “was not effective in monitoring compliance with some mandatory requirements”;
  • A processing and distribution management board for the Veterans Integrated Service Network “did not provide the necessary level of oversight and did not routinely verify the adequacy of some practices” or the accuracy of data;
  • Over the last year and a half, VA medical center managers in St. Louis “have taken corrective actions and some of the conditions identified in the 2011 report have been resolved”;
  • Routine “environment of care” inspections at the center “did not adequately identify and resolve outstanding deficiencies”;
  • The lack of consistent leadership in the processing and distribution section “has contributed to the ongoing P&D problems.”

Responding to the latest evaluation, members of Missouri’s congressional delegation called for further scrutiny of conditions at Cochran. The VA inspector general had launched the initial inquiry after nine members of Congress from Missouri and Illinois asked for an investigation of dental instrument reprocessing there.
“Today’s report is another reminder of the important work that still lies ahead” in improving care at Cochran, said U.S. Sen. Claire McCaskill, D-Mo., in a statement. While she said that it was encouraging that the medical center “has made progress in implementing the VA’s suggestions,” the senator said she plans “to keep a close eye on this situation and ensure we don’t lose any ground in the victories we’ve won for veterans’ care over the past few years.”

U.S. Sen. Roy Blunt, R-Mo., said in a statement, “It is unacceptable that another report has revealed ongoing problems with the medical care the St. Louis Veteran Affairs Medical Center provides to veterans."

Blunt added, “The fact remains that my continued calls for an explanation from the VA regarding the dysfunction at this St. Louis facility remain unanswered, and the problems continue to worsen. Clearly, effective leadership is lacking in several areas, and there’s a disturbing disconnect between the VA Department in Washington and its St. Louis staff.

U.S. Rep. Russ Carnahan – who along with fellow St. Louis Democrat Rep. William Lacy Clay had grilled VA officials about Cochran’s problems last year – called Monday for further scrutiny of training, continuing education and accountability standards at Cochran.

“Our VA Hospital must continue to make the reforms that ensure we protect the veterans who sacrificed so much to protect us,” Carnahan said in a statement. “While improvements have been made in some areas, I fear that the VA IG report may only recommend solutions to prevent this exact mistake from happening again. One step forward, two steps back is simply not good enough.”

Clay said in a statement that the latest inspector general report “makes it clear that while significant progress has been made at Cochran, much work remains to raise the level of care and oversight to the very highest standards that our veterans deserve.”

Clay added: “I will continue building on the close working relationships I have established with the medical and administrative staff at Cochran, and all major veterans groups, to insist that the progress continues.”

The St. Louis VA medical center has been implementing its “Gateway to the Future” plan, developed last year, to improve health services for veterans. Carnahan said he planned to meet this week with officials at Cochran to discuss the Gateway plan and also suggest that they address workplace culture issues that have affected training and accountability of workers and managers.

“We have invested far too much into infrastructure improvements for lapses in training and judgment to continue endangering our veterans,” said Carnahan, a member of the House Veterans' Affairs Committee’s health subcommittee.

Responding to the inspector general’s evaluation, officials at the St. Louis VA medical center concurred in its recommendations. But officials pointed out that a new $7 million “state of the art” sterile processing service is expected to open this month, which will improve the reprocessing of dental instruments. In addition, about $54 million worth of improvement projects are underway at the VA health-care system in St. Louis.

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