Mo. lawmakers say St. Louis VA Center must improve

ST. LOUIS -- Missouri lawmakers raised more concerns Tuesday about care for veterans at the John Cochran VA Medical Center in St. Louis after a government report noted problems, including a nurse's mistake that led to a patient's death.

The Department of Veterans Affairs' Office of Inspector General issued a report Monday that identified leadership problems in the hospital's hemodialysis department. It issued six recommendations for improvement, including developing better ways to measure nurses' competency and better guidelines for how patients' needs will be assessed and who will do it.

The report comes about two years after reports that insufficient sterilization at the center's dental clinic may have exposed more than 1,800 veterans to hepatitis and HIV. Subsequent testing found no link to hepatitis or HIV in any of the patients. Other sterilization concerns briefly shut down surgeries at the center last year, and an inspector general's report in April found that the center still needed to improve its sterilization procedures.

Given that history, Sen. Roy Blunt, R-Mo., called details in the latest report "unacceptable."

"The fact remains that my continued calls for an explanation from the VA regarding the dysfunction at this St. Louis facility remain unanswered, and the problems continue to worsen," Blunt said in a statement. "Clearly, effective leadership is lacking in several areas, and there's a disturbing disconnect between the VA Department in Washington and its St. Louis staff."

Officials at the Cochran center didn't respond to messages requesting comment, but the report said the recommended changes have been made. It wasn't clear from the report if the nurse whose mistake led to the patient's death was fired or disciplined.

In that case, the report said the nurse failed to report changes in the condition of a 57-year-old hemodialysis patient with end stage kidney disease. Emergency efforts failed, and the patient died the next day.

Sen. Claire McCaskill, a Missouri Democrat, said the report "is another reminder of the important work that still lies ahead in ensuring our nation's heroes are getting the best possible care."

Another Democrat, U.S. Rep. Russ Carnahan of St. Louis, said, "One step forward, two steps back is simply not good enough."

The report said the 57-year-old patient had hypertension and diabetes that led to kidney disease and suffered from several other major health problems. He had been on dialysis for nearly a decade when he was hospitalized in December 2010.

The report said the nurse didn't realize the man's condition was getting worse, that he was sleepy and unresponsive after dialysis treatment, even though she and other staff knew him well.

It also noted other problems with the hemodialysis unit, including a lack of leadership and an inadequate policy "for reporting events to the charge nurse or a physician."

Rima Nelson, director of the St. Louis center, said in a written response that "appropriate actions were taken" to correct the problems.