Administrative errors at an Indianapolis Veterans Affairs health center jeopardized the health of numerous patients and forced at least one to lose his foot to a medical amputation, federal investigators announced on Wednesday.

Advocates worry the incidents, which took place two years ago, are indicative of lingering systemic communications problems at the federal bureaucracy. They’re calling for VA leaders to take a closer look at internal communication and oversight protocols.

“Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice,” American Legion National Commander Brett Reistad said in a statement released Thursday morning.

Officials from the U.S. Office of Special Counsel said the mistakes — brought to light by VA whistleblowers — have prompted a series of reforms at the local VA facility and to the larger regional network. But the mistakes did not result in the firing of any officials; one social work assistant chief was reassigned, and a senior chief retired in lieu of reprimand, officials said.

At issue was a decision by VA officials to have social workers stop recording home health care consults into a VA’s patient record system. The move was made due to concerns that the work was outside the responsibilities of the staffers.

But as a result, department officials acknowledged, “this decision led to a system breakdown, as the transition was not implemented with key services in a collaborative and cohesive manner.”

Follow-up visits to veterans after major surgeries and other periodic home check-ups ended up delayed or dropped altogether.

Investigators found in one case, a veteran who had been discharged from the Indianapolis hospital after a diabetes treatment was left to change the dressings on his foot wound himself for several days, even though VA staffers were supposed to do that.

“[His] worsening infection … and subsequent amputation appears to have been related to the delay of the dressing changes by the home care agency,” their report states.

VA investigators completed their report on the issue last summer, but the Office of Special Counsel released their report on problems this week. VA officials said they have updated procedures to allow social workers once again to update information into the patient record system, and trained staff on the proper procedures.

In a letter to the special counsel, VA Secretary Robert Wilkie acknowledged the mistakes constitute “gross mismanagement” by staffers but said the corrective actions should prevent future problems.

In a letter to the White House, Special Counsel Henry Kerner acknowledged those changes but stated that “I am nonetheless distressed that such a situation occurred in the first place.”

Reistad echoed that concern. He praised the whistleblowers who exposed the problems and said VA officials need to do a better job to “identify critical needs and share best practices” within the system.

Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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