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Congress of the United States Bouse of Representatives ‘Wasvirgton, DE 20515-1503 May 16,2019 Dr. Richard Stone, MD Executive-n-Charge Veterans Health Administration US. Department of Veterans Affairs 810 Vermont Ave, NW ‘Washington, DC 20420 Dear Dr. Stone, 1am extremely concerned about the recent report from USA Today ofthe untimely death of a veteran who had been receiving long term nursing care atthe Community Living Center (CLC) at the Des Moines Veterans Affairs Medical Center (VAMC). James “Milt” Ferguson Sr, a91= year-old veteran who served honorably in the U.S. Navy in World War Il died on December 22, 2018 following a fatal fll while under the care of the Des Moines VAMC. We all agree our veterans deserve the highest quality of care, and we are all committed to ensuring thatthe Des Moines VAMC can provide the services the men and women who have served our country have eared, (On December 11, 2018, the one-on-one monitoring of Mr. Ferguson, who suffered from {dementia and legal blindness, was suspended. On December 12, Me, Ferguson was moved from the Des Moines VA psychiatric ward to the CLC. On December 20, Mr. Ferguson suffered an “unsupervised fatal head injury at 3:49pm. It was not until 8:55 pm that an emergency ambulance vehicle arrived atthe facility. Mr. Ferguson passed away on December 22 following a massive brain bleed due tothe injury, ‘The timeline of events raises concerns regarding patient monitoring and injury reporting procedures, n order to better understand what led to this tragic incident and ensure this never happens again, [am seeking answers to the following questions: 1 Has the faitty completed a root cause analysis following the death of Mr. Ferguson? If 50, what was the result of that analysis? f not, when do you expect this analysis to be completed? 2. Why did the Des Moines VAMC determine Mr. Ferguson no longer needed one-on-one strict monitoring? Did the CLC re-assess whether or not strict monitoring was required? is the process for determining which patients receiving care in & CLC need stiet ‘monitoring? Were CLC staff found to have adequately followed this process? Ifs0, were ny revisions made to this process fllowing the death of Mr. Ferguson? 4. What eeporting and response procedures are in place to ensure rapid responce and timely treatment following an accident atthe facility, especially with regard to head injuries? ‘Were those processes followed inthis instance? 5. What are the requirements at the CLC for determining and following patient monitoring, and for head injury reporting? 6. In December 2018, the Department of Veterans AGTairs Community Living Center Survey Repor identified problematic areas forthe Des Moines VA Community Living Center. How has the VHA’s Central Office worked with the Des Moines VA to increase the overall standard of care and remedy the issues found in the aforementioned report? 7. Have additional cases of fatal injuries been reported inthe last two years atthe Des ‘Moines VAMC? IFso, how many, and were proper protocols and procedures followed in those instances? 8, Is the VHA aware of patent fatalities within the Des Moines VAMC that resulted from staff not following policies and procedures? If yes, please provide the appropriation documentation of these fatalities as well as procedures and policies that were not followed in those circumstances. 9. Can the VHA determine if proper VAMC procedure and policy was followed in Mr. Ferguson’s case? Obtaining these answers will help to ease the concers of our veterans and their families, and for that reason, Iam requesting a response from VHA no later than 30 day’ from receipt ofthis Jeter. Our veterans deserve the highest standard of care, and they need to know that VA, standards, policies, and procedures are being met. No veterans or their family member should have to worry they will experience what Mr. Ferguson and his family experienced Ifyou have any questions, you may contact Denise Fleming in my office at either (202) 225- 5476 or», I look forward to your timely reply. a ane Gin “Memher af Congress