Inspectors found dried blood and feeding tubes on the floors, and one patient's leg had to be amputated after maggots were seen falling from his foot, the Pittsburgh Tribune-Review said, citing a report obtained through a federal Freedom of Information Act request.
The report by the Wisconsin-based Long Term Care Institute concluded that the facility, the bed count of which has been cut from 240 to 120, “failed to provide a sanitary and safe environment for their residents.” It cites substandard treatment of wound care and “multiple concerns regarding nursing
“There was a significant failure to promote and protect their residents' rights to autonomy and to be treated with respect and dignity,” the report concluded.
VA spokesman Dale Warman told the paper in an e-mail that many steps had been taken to improve care. A corrective action plan updated on June 29 including the hiring of consultants and additional staff and remedial training and retraining programs for staff, officials said.
The report said no action was taken on one unnamed veteran, even though his toes had turned black, until maggots were observed “falling out of the resident's foot,'' at which point an amputation was ordered. One inspector reported seeing a nurse use the wrong medication despite a week-old order from a physician changing the prescription, the report said.
Some patients had substantial weight loss, including one veteran who lost 51 pounds for unknown reasons.
“The potential for dehydration for these residents presents immediate jeopardy,” the report said.
An internal investigation was triggered three months before the report was issued when David Allen, 56, a mute and disabled Vietnam veteran, choked to death on solid food although he was supposed to be on a soft-food diet.
His death was not mentioned in the report, but the VA said in a statement that the contracts of two agency nurses were terminated and other staff members were given additional training on swallowing difficulties ``as well as the effects of behavioral medications.”