Inspectors have found evidence of abuse, neglect and medication errors at the Claremore Veterans Center. The inspection came just days after an 85-year-old man was scalded to death in a whirlpool bath.
We're finally getting to see this report because the problems at Oklahoma's Veterans Centers are now the focus of a legislative review.
The 85-year-old man scalded to death at the Claremore Veterans Center was totally dependent on others and had trouble communicating. The report states a nurse's aide was bathing Jay Minter in a whirlpool tub for about 15 minutes May 2 when his skin started tearing on his wrist, sloughing off at his ankles and red marks appeared on his back down to his legs.
He had first degree burns on half of his body and second degree burns on 10 percent. Minter died 10 hours later.
The report states the thermometer in the tub wasn't working for a long time before the accident and that nearly half of the facility's whirlpools had faulty thermometers.
Workers are supposed to monitor water temperature daily, but there were only four recorded temperature checks all year. One was somewhere between 126 to 144 degrees.
The nurse's aide said she tested the water with her arm. The center could not prove the aide who bathed Minter had gone through training the year prior.
Minter's death is noted in several of the 15 areas where the Claremore Veterans Center failed to meet VA standards.
Under the "accidents" category, a resident with Parkinson's Disease fell 24 times in five months, resulting in 13 separate injuries. The report says the staff documented each fall but never tried to prevent future falls.
The Center was notified in early June that it failed this inspection. By the end of August, it was back in compliance and fully certified for 2012.
The Center's director has since resigned, and the Oklahoma Department of Veterans Affairs, which oversees the Center, is in the process of hiring a new one.
Officials say the whirlpool has been removed and the center is switching to a shower-only policy, unless the bath is requested.
John McReynolds is the interim executive director of the ODVA. He says he's not satisfied with the Claremore Center and suspects the people who work there aren't either.
He wants the public to know the ODVA is not ignoring the issues at Claremore, but he still believes it's safe for residents.