The report on an investigation into the care of a veteran who died last year at the Tomah VA shows that there were a number of deficiencies in his care.
The report was released from the VA Office of Inspector General Office of Healthcare Inspections.
The investigation came after allegations of over-prescription of medication to veterans at the medical center. The report centers around the care of 35-year-old Marine Jason Simcakoski of Stevens Point who died of mixed-drug toxicity while at the hospital's in patient intensive care unit last August.
"He wasn't getting better, he was getting worse," Simcakoski's father, Marv, said. "In my heart I feel like he had too many different drugs in his system at the end."
The report released by the Inspector General's office said in part that they found that the two psychiatrists who prescribed medication to Simcakoski didn't discuss the risks in administering "hazardous" drugs with him.
"We disagreed with his treatment plan a lot toward the end," Simcakoski said. "That would be my biggest recommendation to other families. Always question things, always be involved."
Rules of the Veterans Health Administration requires written informed consent when prescribing those drugs. The investigation failed to find any evidence that occurred with the use of one of those drugs, buprenorphine.
The report also showed that facility staff didn't respond appropriately when Simcakoski was found unresponsive in his room on August 29, 2014. The document states "Unit staff did not immediately assess the patient and determine the need for cardiopulmonary resuscitation (CPR) upon finding him unresponsive." The report also said that no staff in the building where Simcakoski was found was certified to perform more than basic life support. It did state that "Because the patient's cardiac status at the time he was found unresponsive is unknown, it cannot be determined with any degree of certainty whether resuscitative efforts would have been successful."
Additionally, the report said that "certain medications used in emergency situations to reverse effects of possible drug overdose (naloxone and fluazenil) were not readily available."
Acting Director John Rohrer spoke to the media on the report Friday afternoon at the facility. He acknowledged that the Tomah facility is accepting full responsibility for the treatment of Simcakoski leading up to his death. He also talked about the progress being made on the recommendations made in the report. Among the recommendations were compliance with VHA (Veterans Health Administration) rules on informed consent; review all elements needed to respond effective to medical emergencies; review medications available on emergency crash carts; and determining appropriate administrative action to take, if any.
"When you have issues that occur, of course the staff has been trained in these areas, but when something goes wrong you have to retrain," Rohrer said.
In a statement earlier Friday from the Tomah VA, it stated that, "We are deeply saddened by the tragic, avoidable death of this Veteran and are committed to learning from this event and making improvements in the care we provide to our Veterans. Action plans have been implemented to address the recommendations, with all actions expected to be completed by January, 2016. Tomah VAMC leadership remains committed to improving the care our Veterans have earned and deserve and will continue to keep Veterans and stakeholders informed of our progress as we work on improving service, access and overall quality of care."
The parents of Jason Simcakoski were at the VA for the news conference Friday. Jason Simcakoski's father, Marv Simcakoski, was conciliatory in his remarks. He said he was "really encouraged by the changes" coming as a result of the investigation. "People make mistakes. Nobody is perfect. As long as changes come as a result and they take accountability," he said.