Staff members at a VA hospital in Wisconsin nicknamed "Candy Land" for its increase in painkiller drug prescriptions have been found at fault in the death of a former U.S. Marine last year.
Military Times reported that a Department of Veterans Affairs Inspector General investigation revealed that staff at the VA Medical Center in Tomah, Wisc., did not properly prescribe medications to Jason Simcakoski and fumbled the medical response when he was discovered unresponsive in his hospital bed.
Simcakoski died about a year ago from "mixed drug toxicity" while a patient in the facility’s short-stay mental health unit for anxiety and an addiction to painkillers. The investigation found that the veteran had in 24 hours taken 13 different prescribed medications, several of which are known to cause sedation.
Several medications—including quetiapine, tramadol and others that cause sedation—had been added to his list of drugs by hospital psychiatrists just days before his death.
According to the report, hospital doctors emphasized to investigators that Simcakoski had the ability to leave the medical facility for hours at a time and that he thus likely "obtained additional quantities of his prescription medications on his own and ingested them," thereby causing his own death.
However, the investigation concluded that all of the medications in his system had the potential to cause sedation and that his record "confirmed that all these drugs were prescribed by providers at the facility." Hospital doctors also did not properly advise Simcakoski or his family on the risks of taking the medications.
The report also discovered that staff at the VA facility did not properly determine whether he had a heartbeat, initiate lifesaving measures in a timely manner, use a portable defibrillator or have medications at their disposal that could have thwarted an accidental overdose when Simcakoski was found unresponsive.
"Furthermore, we learned unit staff stopped CPR when facility firefighters arrived [expecting they] would take over the CPR efforts … however, firefighters at the facility are not designated as first-line staff to provide hands on emergency care," the report read.
The Tomah VA facility has endured scrutiny since a report from the Center for Investigative Reporting at the beginning of this year indicated that the amount of opiates prescribed by doctors at the hospital nearly quadrupled over the eight-year period between 2005 to 2012.
One physician found responsible in Simcakoski’s case no longer works at the medical facility and another currently faces administrative procedures.