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Inspector General review faults Manchester VA on stroke procedures

New Hampshire Union Leader

September 08. 2017 11:38AM

MANCHESTER — After reviewing the records of 23 patients who arrived at the Manchester VA Medical Center with stroke symptoms, the VA Office of Inspector General concluded in a report issued Thursday that the medical center did not follow proper VA procedures to treat them for stroke.

The review was triggered at the request of Rep. Ann McLane Kuster, D-N.H., after a 60-year-old Navy veteran, left a prisoner in his own body, was awarded a $21 million malpractice verdict against the Manchester VA center in 2015.

A federal judge at the time assailed the local medical center for “carelessly prescribing the wrong medication” and leaving the patient “medically abandoned.”

The patient, Michael Farley of Bennington, now lives with “locked-in syndrome” after suffering two strokes within two months in 2010. He remains fully conscious but has no voluntary muscle movement other than the very limited ability to move his eyes and his head.

“The purpose of the review was to determine whether system issues may have led to poor care of the patient, and to evaluate changes the facility may have made in response to this incident,” according to the report.

To determine compliance with Veterans Health Administrative policy, inspectors reviewed stroke patient records from June 2014 to May 2015.

“Contrary to VHA policy and process, the (Manchester clinic) was inconsistent in the management of the patient reviews,” according to the report.

The clinic did not always transfer patients to a nearby hospital as required by VHA policy, and did not consistently involve the patient’s primary care physician in emergency treatment.

The inspector general recommended the Manchester clinic “consistently transfer stroke patients to an appropriate acute care facility in accordance with VHA and facility policies and procedures.”

The Manchester VA Medical Center is not a full-service hospital equipped to properly diagnose and treat stroke victims, but is within 2.5 miles of acute care hospitals, the report notes.

The report also calls for a clinical review of 13 stroke patients not transferred “to determine whether patient harm occurred and take action, as appropriate.”

During a follow-up visit in February of 2016, Manchester medical center managers reported on changes made in light of inspector general recommendations.

All Urgent Care Clinic providers at the Manchester medical center have been reminded that a patient’s primary care physician must be alerted to any clinic visits and that all clinic providers have completed stroke management training.

“We appreciate the Office of Inspector General’s review and recommendations for improvement. To date, we have closed two of the IG’s three recommendations and anticipate closing the remaining recommendation this month,” said Alfred Montoya, acting medical center director.

“Since the review, Manchester VAMC has improved its stroke care services by enhancing its documentation practices and establishing an urgent care transfer process to address veterans who present with stroke-like symptoms.”

The report from the VA Office of Inspector General comes as the Manchester VA Medical Center is under fire by a group of doctors and nurses citing a variety of problems in the way the medical center has been managed.

“The report emphasizes the need to improve services for our veterans at the Manchester VAMC and at centers of care around the country,” said Kuster. “While I’m hopeful that the lessons learned from this report will prevent any veteran that suffers a stroke from receiving substandard care, this report still underscores the need to reform the VA’s community care programs, including the Veterans Choice Program.”

At Kuster’s request, the House Veterans’ Affairs Subcommittee on Oversight and Investigations will host a field hearing in New Hampshire on Sept. 18 to hear the whistleblower concerns.

Secretary of Veterans Affairs David Shulkin recently removed the hospital’s top management and ordered a review after the Boston Globe reported on the whistleblower complaints.

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