Inspector General's Report Addresses Grand Junction VA Health Care Concerns
Vietnam War veteran Rodger Holmes became ill in 2014, at the height of a national scandal over long patient wait times at care centers and allegations of negligence at the Department of Veterans Affairs. Holmes, who sought care for his Hepatitis C liver disease at the Grand Junction VA Health Care System, was among those to complain.
"He lost a tremendous amount of weight," said Chris Blumenstein, who served as a VA social worker to Holmes. "He was losing his mental clarity, his mental sharpness, he couldn't remember things."
Holmes died in December 2014, but in response to concerns, the VA's national Office of Inspector General launched an investigation and released recommendations May 11, 2016.
"We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability," inspectors wrote.
U.S. Sen. Michael Bennet was among lawmakers to express concern.
"This was a tragic situation and Sen. Bennet thinks that the Grand Junction Medical Center should adopt the recommendations made by the Inspector General's office in an attempt to ensure this doesn't happen again," said Bennet spokesman, Adam Bozzi.
Paul Sweeney, the Grand Junction VA's chief of public relations, said several changes are already underway. He acknowledged that the VA center did not have Hepatitis C doctors in place during Holmes' care. Now, he said, the center has an expert to improve Hepatitis C care. Other medical specialists have also been added to the center that serves 37,000 patients on the Western Slope.
"One of the things that was learned is that there is a lack of depth in some of our specialties," Sweeney said.
Inspectors substantiated just one of Blumenstein's initial allegations, which was "that the patient received inadequate follow-up care leading to further hospitalization."
"The circumstances of discontinuity of care and the lack of a thorough analysis of the patient's condition may have contributed to his progressive decline and slower recovery," investigators wrote.
Grand Junction VA Medical Center Director Marc Magill disputed that finding.
"We believe the review of encounters below supports appropriate clinical care was provided to this veteran [Holmes]," Magill wrote in a letter to investigators.
Investigators did not connect Holmes death to his care.
Blumenstein, who quit his job in 2014 to protest what he alleged was a lack of follow-up care and a lack of access to a specialized Hepatitis C doctor, was disappointed the other allegations were unsubstantiated. Still, he views the investigation as a victory for Rodger Holmes.
"The important thing is his legacy for improved health care," Blumenstein said.
Read The VA Inspector General's Health Care Inspection [.pdf]