Memphis medical center inspected for inadequate - Action News 5 - Memphis, Tennessee

Memphis medical center inspected for inadequate care after patient deaths

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The Department of Veterans Affairs has come under fire nationwide for a list of issues ranging from infectious disease outbreaks to veterans deaths. The Department of Veterans Affairs has come under fire nationwide for a list of issues ranging from infectious disease outbreaks to veterans deaths.
Lisa Coleman's father was a 74-old-year Vietnam War veteran who died at the VA hospital on Easter Sunday last year. Lisa Coleman's father was a 74-old-year Vietnam War veteran who died at the VA hospital on Easter Sunday last year.
Lisa Coleman has no proof that her father's death was a result of negligence, but other fatal cases exposed in an OIG investigation raise new questions about his care. Lisa Coleman has no proof that her father's death was a result of negligence, but other fatal cases exposed in an OIG investigation raise new questions about his care.

(WMC-TV) - The Office of Inspector General conducted an inspection in the emergency department at the Memphis VA Medical Center after an allegation of inadequate care for patients who died.

The first complaint was filed when a patient died after he or she took medication, which he or she had a known drug allergy to. Another patient died after being administered multiple sedating drugs; he or she was not monitored properly after given the drugs. A third patient died after delays in getting treatment for very high blood pressure, which caused bleeding on the brain.

"Like other hospital systems, VA isn't immune from fatal human error. But what the department does seem to be immune from is meaningful accountability," said the State Representative of the House Committee on Veteran's Affairs, Jeff Miller-Chairman.

The Department of Veterans Affairs has come under fire nationwide for a list of issues ranging from infectious disease outbreaks to veterans deaths. The OIG links these problems to widespread mismanagement within VA facilities among other things.

"Three out of the thousands ... As tragic as they are is to me infinitesimal," said Vietnam veteran Fred Spann, who is a double amputee patient being treated at the VA. "The doctors, the nurses, everyone I've had an association with has been great."

After an inspection, the OIG found the facility had completed protected peer reviews of the care for all three patients. It has been recommended that processes be strengthened to improve patient monitoring in the emergency department and that competency assessments be completed for the nursing staff.

"It's well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible," said Miller.

The Veterans Integrated Service Network and facility directors agreed with the recommendations and provided an acceptable action plan.

"We take these issues very seriously," said VA Medical Center Chief of staffs Dr. Christopher Marino. "The office of the Inspector General released a report on an investigation they performed in May of 2013 on three deaths that occurred in our emergency department over one year ago. The physician involved in the care of two of the patients referenced in the report no longer works at our medical center."

Marino says ER patients are now placed on cardiac monitors and observed by ER staff as well centralized monitor technicians. A second monitoring system has been installed for the less critical patients in the ER.

Marino says families of the deceased patients have been fully briefed.

But these deaths at the Memphis VA Medical Center are forcing people to ask if their loved ones experienced the same fate. Lisa Coleman's father was a 74-old-year Vietnam War veteran who died at the VA hospital on Easter Sunday last year.

"He went to the ER that Thursday, and they sent him home," she said.

The next day Laymon Coleman returned to the ER and was admitted, and a little more than 24 hours later he was gone.

"I could see them shaking him ... I said, 'Oh, I got to get to the room. I got to run.' And get to the room and when I got up there they said he was dead," said Coleman.

The official cause of death was a blood clot in his lung.

Lisa Coleman has no proof that her father's death was a result of negligence, but other fatal cases exposed in an OIG investigation raise new questions about his care.

"They shouldn't have sent him home. They should have kept him the first time," she said.

Coleman was the father of six and the grandfather of nine who not only served his country but worked at the VA hospital for 54 years.

"Just tragic ... [I] don't understand why it happened. I miss my dad a lot. And I just wasn't ready for him to go," said Coleman.

Coleman says her prayers have been answered by the investigation of these cases.

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