Sophia Tareen, AP
Serious safety issues continued to plague a southern Illinois Veterans Affairs hospital even after major surgeries were suspended two years ago because of a spike in patient deaths. Surgeons at the medical center performed procedures without proper authorization, patient deaths were not assessed adequately and miscommunication between staff members persisted, the Veterans Affairs Department's inspector general said in the report, which covers the fiscal year that recently ended.
The medical center's “oversight and reporting structure was fragmented and inconsistent, making it difficult to determine the extent of oversight or the corrective actions taken to improve patient care,” the report said.
The hospital has been under intense scrutiny since 2007 when a former surgeon resigned three days after a patient bled to death following gall bladder surgery. All inpatient surgeries were suspended within a month. The VA found that at least nine deaths between October 2006 and March 2007 resulted from substandard care at the hospital, which serves veterans from southern Illinois, southwestern Indiana and western Kentucky. The VA said 10 patients died after receiving questionable care that complicated their health.
The hospital still isn't performing major surgeries, though some outpatient procedures are performed there. A hospital spokesman said Monday the facility had no immediate comment, but the report included memos from the medical center's interim director saying the hospital has corrected or is in the process of correcting the issues.
The inspector general's 30-page report said the hospital did not sufficiently monitor 87 percent, or 20 of 23 of its physicians, to ensure they could perform procedures competently. There also were problems with infection control — including a patient with a history of MRSA staph infections wrongly put in a room with two other patients and a shared a bathroom.
The hospital also had problems with tracking deaths. For example, there were three different tallies for April 2009. Minutes of the hospital's executive board showed five deaths, a patient statistics report showed six deaths and another set of documents listed seven, according to the report. In another instance, surgical staff knew two people died after surgery but their deaths didn't appear to have been reported to management, the report said.
The inspector general has called for a redesign of the hospital's overall reporting structure and vowed to continue investigations until all the issues are resolved.