USA Today had the tragic and preventable story of James “Milt” Ferguson Sr., a blind World War II veteran, who died from a head injury suffered at a VA nursing home in Iowa. Ferguson was removed from one-on-one supervision, and he wandered into other residents’ rooms repeatedly, medical records show. When he rolled his wheelchair into one room unsupervised Dec. 20, 2018, his son said VA staff told him the resident of the room flipped Ferguson backwards out of his wheelchair. He landed on his head, causing a massive brain bleed.  A surveillance camera captured footage of James Ferguson Sr.’s fatal injury at a Veterans Affairs nursing home.

People are outraged that he wasn’t monitored more closely and what policies are in place to prevent a similar injury or death.  A USA TODAY investigation that chronicled Ferguson’s case and what specialists say was a concerning series of decisions by VA staff, before and after his deadly injury.

Nursing staff didn’t report the incident for 40 minutes, according to the records and surveillance video. They didn’t take him to the emergency room for more than two hours and he wasn’t transferred to a trauma hospital until five hours after the fall. He died from the injury two days later.
Ferguson was admitted to the acute psychiatry ward at the VA Medical Center in Des Moines in November after his dementia worsened. He had been in a private nursing home but became aggressive and wandered into other residents’ rooms. VA healthcare providers adjusted his medications and placed him on one-on-one observation with an aide to prevent him from straying into other rooms.

But on Dec. 11, 2018, staff removed the strict observation even though he was still determined to be a danger to himself and others, the medical records show. He was transferred to the VA nursing home on the medical center’s campus the next day. Ferguson continued to enter other residents’ rooms repeatedly, but records show staff did not reinstate strict observation.

After the head injury at 3:49 p.m. Dec. 20, Ferguson wasn’t taken to the emergency room until about 6:30 p.m., and he wasn’t transferred to a trauma hospital until 8:55 p.m.

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