Inadequacies in Patient Safety Reporting Processes and Alleged Deficient Quality of Care Prior to a Patient’s Foot Amputation at the Edward Hines, Jr. VA Hospital in Hines, Illinois

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, to assess an allegation that deficient quality of care resulted in a patient’s foot amputation. The patient told facility primary care staff about falling at home while wearing VA-issued diabetic shoes. At the time of the fall, the patient had temporarily stopped taking anticoagulation medication, as instructed, for a procedure. The patient told clinical staff of symptoms consistent with an arterial occlusion 11 and 12 days after the fall; staff referred the patient to an emergency department. The patient elected to wait and go to the facility for diagnostic testing, and later underwent a foot amputation due to an arterial occlusion. The facility’s vascular surgeon told the OIG that the arterial occlusion may have been caused when the patient stopped anticoagulation medication (prior to a bleeding-risk procedure) or possibly due to the fall. Pharmacy staff managed the patient’s anticoagulation medication in accordance with Veterans Integrated Service Network and facility guidance. The day of the fall, a podiatrist saw the patient for an annual evaluation and gave instructions to wear the previously provided VA-issued shoes, a type of shoe with known challenges related to fit and heel slippage. The OIG determined that the podiatrist missed an opportunity to provide reeducation or refit the patient with new VA-issued shoes. The patient attributed the fall to the shoes and reported concerns to the facility’s patient advocate. The OIG found that the patient advocate did not consult with the facility’s patient safety staff, as required, after receiving concerns from the patient alleging facility staff’s negligence led to the amputation. The OIG made two recommendations related to consulting with patient safety and refitting and reeducating patients on VA-issued shoes.