Rep. Cindy Axne, D-Iowa, is demanding answers from the Department of Veterans Affairs about the death of a World War II veteran from a head injury at the VA nursing home in Des Moines, Iowa.
Axne wants to know why James “Milt” Ferguson Sr., a legally blind 91-year-old with dementia, wasn’t monitored more closely and what policies are in place to prevent a similar injury or death.
“No veterans or their family member should have to worry they will experience what Mr. Ferguson and his family experienced,” Axne wrote in a letter to the VA Thursday.
Her concern follows a USA TODAY investigation that chronicled Ferguson’s case and what specialists say was a concerning series of decisions by VA staff, before and after his deadly injury.
Ferguson was removed from one-on-one supervision, and he wandered into other residents’ rooms repeatedly, medical records show. When he rolled his wheelchair into one room unsupervised Dec. 20, 2018, his son said VA staff told him the resident of the room flipped Ferguson backwards out of his wheelchair. He landed on his head, causing a massive brain bleed.
Nursing staff didn’t report the incident for 40 minutes, according to the records and surveillance video. They didn’t take him to the emergency room for more than two hours and he wasn’t transferred to a trauma hospital until five hours after the fall. He died from the injury two days later.
In her letter to VA headquarters in Washington, Axne asked about resident supervision policies, and reporting and response procedures for accidents, including head injuries.
“The timeline of events raises concerns regarding patient monitoring and injury reporting procedures,” she wrote. “Our veterans deserve the highest standard of care, and they need to know that VA standards, policies and procedures are being met.”
VA national spokesman Curt Cashour said agency officials “will respond to the representative directly.” He referred to an earlier statement from Des Moines VA spokesman Timothy Hippen that said a policy review after the “untimely death” concluded “all staff acted properly.”
In response to inquiries from USA TODAY, Hippen and Cashour have declined to say what policies are in place to prevent such traumatic injuries at the VA nursing home in Des Moines or elsewhere. More than 40,000 veterans rely on care each year at the VA’s 134 nursing home across the country.
Axne said in an interview Thursday that she had spoken with Ferguson’s son, and he “obviously still has questions and believes internal policies weren’t adequate.” She asked VA for responses to her questions within 30 days.
“I want to know how this happened so that we can make sure that it never happens again,” Axne said.
Ferguson was admitted to the acute psychiatry ward at the VA Medical Center in Des Moines in November after his dementia worsened. He had been in a private nursing home but became aggressive and wandered into other residents’ rooms. VA healthcare providers adjusted his medications and placed him on one-on-one observation with an aide to prevent him from straying into other rooms.
But on Dec. 11, 2018, staff removed the strict observation even though he was still determined to be a danger to himself and others, the medical records show.
He was transferred to the VA nursing home on the medical center’s campus the next day. Ferguson continued to enter other residents’ rooms repeatedly, but records show staff did not reinstate strict observation.
After the head injury at 3:49 p.m. Dec. 20, Ferguson wasn’t taken to the emergency room until about 6:30 p.m., and he wasn’t transferred to a trauma hospital until 8:55 p.m.
Hippen, the Des Moines VA spokesman, has declined to answer detailed questions about what happened. He said that in general, “caring for nursing home residents involves balancing patients’ independence with the need for supervision, as appropriate.”
Ferguson’s son Jim said Thursday that he is grateful for Axne’s help in getting more answers about his father’s care.
“Now that I have had time to sit back and seen everything and thought about everything, I think, it’s horrible,” he said. “I hope they make changes.”
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