LOUISVILLE, Ky. — A national report says the Louisville VA hospital on Zorn Avenue, allowed an unrelated neighbor to make medical decisions for a veteran.
While the initial investigation was about this veteran, they found a lot of deficiencies when it comes to patients' rights.
The new report from the V-A Office of the Inspector General says a 70-year-old patient came to the Robley Rex V-A Medical Center in the Spring of 20-19 complaining of back pain. They were later flagged for a psychiatric evaluation, involuntarily admitted and physically restrained intermittently for 16 days.
The report also states the center allowed a neighbor with no legal authority to make medical decisions. The patient died several weeks after being admitted.
"It seems like an amateur mistake for a lack of a better term and I was just really surprised when I heard that," said Jeremy Harrell who is the Founder and CEO of Veteran's Club.
He partners with the V-A and says there's already a lot of mistrust for veterans seeking help. "It just gives them an out for going there for their care and oftentimes because of that, they don't get any care. And of course, we know that's detrimental for the veteran community if they don't seek treatment," Harrell said.
The national report goes on to say that the patient did have family that they notified of the death. The report found multiple deficiencies against patient rights, management and the facility's response.
"We can't negate the fact that that was a breakdown in process and I think they know that more than anybody," said Harrell.
In a statement, a spokesperson for the medical center says, 'This report focuses on an event that occurred over a year ago. Since then, Louisville VA Health Care System has completed a top-to-bottom review of its administrative processes in support of diagnoses, treatment decisions, continuity of care and hospice transfer processes.
Since the incident, the facility has implemented changes including developing a new process to ensure a comprehensive search for next of kin is undertaken before identifying an alternative decision-maker.
They've also implemented a way to alert providers electronically when a patient no longer has decision-making capacity.'
Harrell says he's seen a lot of change in the last year, including the Medical Center Director, Steven Black, who took over in early 2019, "I've seen major improvements in all facets in how it's ran now through Mr. Steven Black and I don't foresee this happening again."
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