'Deficiencies in care' led to patient death at Batavia VA: inspector general report

BUFFALO, N.Y. (WIVB) — Alleged 'deficiencies in care' led to a patient death at a Batavia community living center run by the VA Western New York Healthcare System, according to a report from the VA Office of Inspector General.

The report revolves around a patient simply known as 'Resident A.' The resident, who was in their 70s, was admitted to the Buffalo VA in late 2024 for "increasing combativeness, agitation and confusion." The resident had a history of dementia, anxiety and diabetes. Inpatient medication included periodic single doses of haloperidol for agitation.

The patient was discharged from the Buffalo VA to the Batavia clinic for long-term care. At the Batavia living center the dose of haloperidol was increased and it was noted that the resident needed "extensive assistance with daily activities, including eating."

At the resident's first night in Batavia the resident fell but was not injured and a nurse documented normal vital signs but an elevated blood sugar level.

On the resident's 16th day, a physician ordered bloodwork to monitor diabetes and electrolyte levels. Four days later, the resident had a fingerstick blood sugar level completed, which was elevated at 349 milligrams per deciliter. The report states that a normal level is 70 to 115 milligrams per deciliter.

On the resident's 23rd day, a nurse noted that the resident was "lethargic, did not respond to voice, and had abnormal vital signs." The resident's blood sugar was registered at over 600 MG/DL. The resident was then admitted to the ICU. On day 36, the resident was transferred to the Buffalo VA for hospice and died two days later.

The results of the investigation showed that there were "deficiencies in care" including "physician and nursing staff management of Resident A's dementia and diabetes" as well as "nursing documentation of medication administration and nutritional intake." It further found "deficiencies in provider staffing and nurse education that increased risk to patient safety and may have contributed to Resident A's functional decline."

The VA said in a statement Friday that the employee who was overseeing the veteran's care is no longer with the VA.

"The entire VA Western New York Healthcare System team grieves for the loss of this Veteran," the VA Western New York said in a statement Friday. "We are working closely with the Batavia Community Living Center to implement the recommendations provided by the Office of Inspector General, ensuring that all Veterans receive the highest quality of care that they deserve.“

This is now the second report from the inspector general in the past year. In September 2024, the office released a report involving dozens of patients having their care delayed at the Buffalo VA Medical Center, located on Bailey Avenue. The patients, for the most part, were attempting to receive care in 2022 or 2023. In one case, it took more than 300 days for a patient to receive care.

One month before that, the VA healthcare system director and chief of staff were both transferred out of their positions due to "concerns raised by clinicians about local leadership and instances of delayed care.”

"I am appalled by the findings of the recent OIG report detailing devastating failures in care at the Batavia Community Living Center," Congressman Tim Kennedy (NY-26) said in a statement Friday. "It is completely unacceptable that deficiencies in care contributed to a veteran's death and that similar issues were found with another resident. The report's findings, including preventable failures in dementia and diabetes care, poor documentation, and a lack of accountability from leadership, indicate a systemic breakdown that puts our veterans at risk."

Nationally, the VA cut nearly 17,000 jobs before June 1 this year and plans to cut another 12,000 by the end of the year. Those more recent numbers came after an internal memo was sent in March that the Trump administration planned to cut 80,000 VA jobs. As of June, the VA had around 467,000 employees nationwide.

"This was a catastrophic failure of leadership, oversight, and basic care. Just as I fought to overhaul the failed leadership at the Buffalo VA," Congressman Nick Langworthy (NY-23) said. "I’m now demanding the same level of accountability and sweeping reform in Batavia. I’m actively working with VA Secretary Doug Collins to ensure this never happens again."