Congressman Russ Carnahan (D-MO), member of the Health Subcommittee of the House Veterans' Affairs Committee, today called for additional examination of training, continuing education and accountability standards at the John Cochran division of the St. Louis Veterans Administration Medical Center (VAMC) and for those standards to be addressed by the VAMC.
Rep. Carnahan's request for this internal examination comes in response to a report issued Monday afternoon by the Office of the Inspector General (IG) of the Veterans Administration, indicating that in early 2011, a Licensed Practical Nurse (LPN) at the Cochran facility failed to recognize and report changes in the condition of a patient during hemodialysis. As a result, the patient fell into a coma and died.
The report also cites the lack of a strong leadership presence in the nurse manager and charge nurse roles, "There was no defined responsibility for the charge nurse and no policy for reporting events to the charge nurse or a physician."
"Our VA Hospital must continue to make the reforms that ensure we protect the veterans who sacrificed so much to protect us," said Carnahan. "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.
"I understand this tragedy happened over a year ago, that it is just being made public and that St. Louis VAMC completed the alterations recommended by the IG. However, we must guard against other potential problems that could develop from a systemic failure of training and monitoring at Cochran. We owe the men and women who served this nation an honest effort to make certain that, if foreseeable problems exist, we attack the root causes of those problems."
In response to previous issues, St. Louis VAMC authored their "Gateway to the Future" plan which would, "move veterans' services forward." This plan was finalized in 2011 and is currently being implemented by the VAMC. Rep. Carnahan will be speaking with officials from St. Louis VAMC and the Cochran facility this week to voice his desire that improvements to the hospital not only include this "Gateway" plan, but also seek to investigate and remediate any workplace culture issues at the hospital which have impacted training and accountability of both employees and management.
"I will continue to monitor the improvements at Cochran closely," said Rep. Carnahan. "We have invested far too much into infrastructure improvements for lapses in training and judgment to continue endangering our veterans."