Last summer, Vietnam veteran Rodger Holmes went to the VA Medical Center in Grand Junction with a long-standing case of Hepatitis C. At the time, he was functional and able to work as a volunteer for 20 hours a week. But once he enrolled in treatment at the VA, his health declined dramatically, alleges Chris Blumenstein.
In December, Holmes entered a hospice in Grand Junction where he died, surrounded by family.
“His stomach swelled up to the size of a bowling ball,” Blumenstein says. “He experienced nose bleeds and his cognitive condition deteriorated to such an extent that he couldn’t keep track of information from one moment to the next.”
Blumenstein says Holmes' troubles began with medicine Holmes was given. Blumenstein was Holmes’ social worker and responsible for tasks like shuttling Holmes to and from medical appointments. He says he tried to help improve Holmes’ care, including going to his superiors, but his efforts were brushed off. In July, Blumenstein quit his job in protest.
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Now, the VA's Office of Inspector General (OIG) in Washington, D.C. is reviewing the case. Specifically, the OIG's Office of Healthcare Inspections will make the inquiry, CPR News has learned. The review is likely produce a report, though when it is finally issued, Holmes’ name may be omitted from it for privacy concerns.
The medical center in Grand Junction confirmed that it has been contacted by the OIG. Paul Sweeney, a spokesman there, declined to address questions about Holmes’ treatment. Nor did he address several of Blumenstein’s allegations, citing policy not to discuss matters that could be under investigation.
Blumenstein claims that as Holmes' health faltered, the patient asked to be seen by a liver specialist. After he was told one wasn't available, he sought a transfer to VA care elsewhere, but was denied, Blumenstein alleges.
Prior to the inspector general’s involvement, Sweeney had discussed some aspects of Grand Junction VA care with CPR News. He acknowledged the medical center in Grand Junction does not have a specialist who can provide care for patients in need of extensive Hepatitis C treatment.
“All of our Hep C patients are now being seen through Denver and a tele-health program,” Sweeney said. “So Denver’s managing their care because we don’t have anybody on staff who has certification for Hep C.”
The medical center gave up management of such patients in September or October, Sweeney said.
That’s months after Blumenstein quit his job.
Holmes spent 10 weeks at the Grand Junction medical center and was ultimately released to be treated at home with nursing care. But his health continued to decline, Blumenstein says. By December, Holmes' condition was dire before his death.
Several lawmakers had prodded the VA's Office of Inspector General to review the case, including U.S. Sen. Michael Bennet. And, earlier this month, the state Legislature’s joint State, Veterans and Military Affairs committee sent a letter calling for a thorough investigation. In part, the letter states:
Detailed reports, emails and medical-chart documentation generated at the time by Mr. Holmes’ VA social worker show not only the disorganization and insufficiency that characterized Mr. Holmes’ liver care, but also demonstrate that complaints by the social worker to the hospital chief of staff, the hospital chief of medicine, the hospital chief of mental health and the hospital safety office -- to whom the Hepatitis C program pharmacist also complained -- failed to improve the quality and safety of Mr. Holmes’ care. Throughout his 10-week hospitalization -- first on a medical floor and for two months in the on-site nursing home wing -- Mr. Holmes’ requests for specialty liver care from someone not implicated in his mismanaged treatment were denied; they continued to be denied after his release to home -- supported by three-times-a-week home nursing -- on June 19; and they continued to be denied up until the time of his death.
