Tomah VA "acted appropriately" in death of 74-year-old veteran, his daughter disagrees
The report by the Department of Veterans Affairs Office of Inspector General wrote they \"did not substantiate the general allegations of poor care and delayed care\" for 74-year-old Thomas Baer, who died on January 14th, 2015.
Baer told his family he wasn't feeling well two days prior and was taken the Tomah VA's Urgent Care Center.
It's there his family said he waited for three hours to be seen and his signs of a stroke were put off until it was too late.
We spoke with Baer's daughter, Candace, in February after initially making the allegations against the Tomah VA.
Thursday night she told CBS 58 that she's hurt by the Inspector General's conclusion in her father's death.
\"We concluded that, overall, the [Urgent Care Clinic] staff acted appropriately in the face of a patient experiencing a sudden and unexpected acute ischemic stroke while waiting for a mental health evaluation in a rural hospital that is not equipped to treat a health problem of this magnitude,\" the report said.
It also claims that it did not substantiate that Baer waited for 3 hours before being seen and that UCC staff were dismissive of the signs and symptoms that the patient exhibited.
Instead the report claims said Baer waited two hours and sixteen minutes to see a physician, but only after having a stroke and suddenly slumping over in his wheelchair in the waiting area at approximately 1:25 p.m. on the 12th of January. He was checked into the clinic around 11 a.m. that day.
\"Well, it's ridiculous because the only reason they saw him when they did was because they had no other choice,\" Candace Baer explained.
Baer's daughter said she's not buying any of the explanations in the report and called reading the report a waste of time.
Wisconsin Senator Ron Johnson sent a statement on the report:
“My thoughts and prayers are with the Baer family. This report leaves many questions unanswered. My committee will continue to fight for transparency and accountability in the VA on behalf of Wisconsin veterans.”
Fellow Wisconsin Senator Tammy Baldwin also sent a statement adding:
“My sympathies remain with the Baer family for their loss and my heart goes out to them. The problems at the Tomah VA are in need of solutions and I am going to continue my work to address these problems and put reforms in place to prevent these tragedies from ever happening again.”
The report identifies opportunities for improvement but it said none of them could have impacted the care of Thomas Baer.
Improvement recommendations include:
1. We recommended that the Under Secretary for Health review current acute stroke
treatment policies, and assess the use of telehealth evaluation and more aggressive
local treatment in patients presenting to rural and/or low complexity VHA facilities with
signs and symptoms of an acute stroke.
2. We recommended that the Under Secretary for Health review processes to improve
the ability to identify unauthorized access to VA medical records.
3. We recommended that the Under Secretary for Health evaluate the complex rules
related to reimbursement for a veteran's emergency care at non-VA facilities, and
determine if changes in policy or law would make it more likely that veterans would
make decisions on where to seek emergency care based upon medical circumstances,
rather than fear of adverse financial impact.
4. We recommended that the Facility Director ensure that patients and their families are
educated about the services the UCC is equipped to provide.
5. We recommended that the Facility Director ensure that employees who are involved
in assessing and treating stroke patients receive the web-based acute ischemic stroke
training required by the facility and that facility managers monitor compliance.
6. We recommended that the Facility Director ensure that transfer agreements are
established as required.
7. We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
8. We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
9. We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.