Citation Nr: 1522231 Decision Date: 05/26/15 Archive Date: 06/11/15 DOCKET NO. 13-21 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUE Entitlement to compensation under 38 U.S.C. 1151 for methicillin resistant staphylococcus aureus (MRSA) claimed to have resulted from VA medical treatment. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Finn, Counsel INTRODUCTION The Veteran served on active duty from June 1974 to August 1975, during the Vietnam Era. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Anchorage, Alaska. The Board has reviewed the Veteran's claims files and the record maintained in the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS) to ensure complete consideration of all the evidence. FINDINGS OF FACT 1. In July 2009, the Veteran received VA treatment for blisters on his hands. 2. The Veteran was diagnosed with MRSA in August 2009. 3. The Veteran experienced an additional disability of residuals of MRSA that include, sepsis, pneumonia, and bone infections. 4. The VA treatment and subsequent MRSA infection was not characterized by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or that the proximate cause was an event that was not reasonably foreseeable. CONCLUSION OF LAW The criteria for compensation under the provision of 38 U.S.C.A. § 1151 for an additional disability of residuals of MRSA to have been caused by VA treatment have not been met. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2014); 38 C.F.R. § 3.361 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2014); 38 C.F.R. § 3.159(b) (2014); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). The record reflects that the Veteran was provided with VCAA notice in November 2011 and July 2012, which informed him of his and VA's respective duties for obtaining evidence, and was provided prior to adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). He was advised of the manner in which effective dates and disability ratings are assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The RO has obtained the Veteran's STRs (service treatment records), post-service VA, and private treatment records. The Veteran has not identified any additional records that he wished the RO to obtain. Further, a VA examination was conducted in February 2013. The examination report is adequate because the appropriate evaluation was conducted following a full review of the record; the report is factually informed and fully explained. Although the Veteran asserts that the VA examiner was bias, the Board finds the report well-written with an opinion based on the factual record. The Board cannot find a VA examination inadequate based on generic assertions by the Veteran. Further, the Veteran has not proffered any opinion contrary to the February 2013 VA examiner's opinion. The RO obtained medical records, scheduled the appropriate VA examination, and readjudicated the claim as necessary. All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Accordingly, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of this claim. II. Merits of Claim The Veteran asserts that he suffers from residuals of MRSA due to not being properly diagnosed or treated by the VA. (See July 2013 VA Form 9). The preponderance of the evidence is against a finding of any fault on VA's part, and the appeal will be denied. Under VA law, when a Veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2014); 38 C.F.R. § 3.358(a) (2014). To be awarded compensation under section 1151, the Veteran must show that VA treatment (or other qualifying event) resulted in additional disability, and further, that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of the disability was an event which was not reasonably foreseeable. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. To determine whether additional disability exists, the Veteran's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other relevant incident in which the claimed disease or injury was sustained upon which the claim is based, is compared to the Veteran's condition after such treatment, examination or program has stopped. 38 C.F.R. § 3.361(b). If an additional disability exists, the next essential determination is whether the causation requirements for a valid claim for benefits have been met, to consist of both actual and proximate causation. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran's additional disability. If it is shown merely that a claimant received medical care or treatment, and has an additional disability, that in and of itself would not demonstrate actual causation. 38 C.F.R. § 3.361(c)(1). Also, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment or other instance of fault proximately caused the additional disability, it must be shown that VA failed to exercise the degree of care expected by a reasonable treatment provider, or furnished the treatment at issue without informed consent. 38 C.F.R. § 3.361(d)(1). Proximate cause may also be established where the additional disability was an event not reasonably foreseeable, based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable medical provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA is required to consider the type of risk that a reasonable health care provider would have disclosed as part of the procedures for informed consent (in accordance with 38 C.F.R. § 17.32). 38 C.F.R. § 3.361(d)(2). In October 2008, the Veteran was seen for "blisters on his hands." At this visit, Dr. Laufer discontinued medications as he felt these might be the cause of the blisters. The Veteran was referred to dermatology for a work-up of the skin lesions. In December 2008, a VA dermatologist provided a provisional diagnosis of porphyria cutanea tarda and ordered a 24 hour urine test for porphyrins. In April 2009, the Veteran was seen by his primary care provider (PCP). There was no mention of his hand condition at that visit. On July 7, 2009, Dr. Lacy examined the Veteran for lesions on the dorsum of his hands that "occur[ed] during the summer." There was no evidence of abscess or lymphadenopathy. He was diagnosed with xeroderma and given triamcinolone. The HPI noted that he "gets the hand sores in the summer on the dorsum and uses OTC HC or antibiotic ointment. He has seen dermatology in 12/08 (see note) and had the PCP order various tests. No treatment seems to be permanent." On July 24, 2009, the Veteran was diagnosed by Dr. Lacy with cellulitis of the hands and placed on Doxycycline 100 mg bid x 15 days. The note stated "hands draining x a few weeks. He squeezes gets pus out. Has seen derm 12/08 but the 24 hour urine was not done. He thinks it might be due to the home brewed beer. He has HCV and also acts a little like Lichen planus." A July 24, 2009 addendum notes "Anchorage lab called. Culture was inadvertently frozen in cooler during transport to Anchorage." Another July 24, 2009 VA treatment record noted that the reason for visit was "Vet in for open blisters on dorsum of bilateral hands. Treatment of 'ointment was helping, but getting worse.' Some swelling of rt hand. Draining white creamy stuff, no drainage seen at this time from hands. Vets meds were reviewed and no problems or concerns noted." Another July 24, 2009 VA treatment record noted that "PT with hx skin lesions, seen by Dr Young and Dr Lacy, most recently prescribed TAC. Pt noted initial improvement on Tac, but when new lesions recurred they presented as pustules, which have now erupted and are draining purulent material. PT has been manipulating lesions, 'squeezing out pus and meat. My hands are rotting from inside.' Lesions on dorsum right hand, right thumb, left hand, left wrist, now with redness/warmth/pain. Pt notes one episode chills last night, has not taken temperature. PT advised he had lab ordered by Dr Young to try to determine origin of issue that he needs to have lab drawn if timing with courier and sends out [was] appropriate." There was no red streaks, from the skin lump or bump or vomiting, but the skin lump was painful and swollen. Additional comments reflect "Mat Su CBOC-Veteran with complaints of continued sores on both hands; feels the infection in hands [was] deep within. Prescription provided by Dr. Lacy [was] not working." On August 4, 2009, a routine CBC showed a normal white blood cell count, but noted "Porphyrins were positive (see results below) and the Veteran was referred for phlebotomy (treatment of porphyria). Veteran calls asking what the next step is regarding his hand condition. ANP note states 'defer to PCP.'" On September 8, 2009, treatment records reflect that the Veteran called wondering what the next step was in the care of his chronic hand blisters. There were no signs of infection that day, but it was on-going problem for him. A September 16, 2009 VA treatment record reflects that the Veteran reported that he "followed through with dermatology recommendation of having phlebotomy with no noticeable results as he continue[d] to have new blisters on his hands every day. Review of CRPS records show[ed] culture was obtained but froze on way to lab. Veteran invited in for lab appointment to obtain new culture." Veteran stated he would attend. The record also stated "Spoke with Elmendorf Phlebotomy/transfusion department. Veteran has been in 3 times for blood withdrawal. At last phlebotomy appointment September 3rd, 2009 he was told he would need to come in till his levels were normal. Veteran did not schedule appointment after September 3rd. Will speak with Veteran today at 11:00 appointment to reiterate treatment regime and address educational needs related to liver function, alcohol abstinence, and treatment program." A September 16, 2009 addendum reflects "Spoke with Veteran [was] here for wound culture and reiterated need to keep phlebotomy appointments as part of his treatment regime for his skin condition. Veteran also stat[ed] he [was] still drinking. Veteran advised to stop drinking and smoking as both these activities impair[ed] his body's healing process. Veteran verbalized understanding. Dr. Lacy in briefly to speak with Veteran and prescription given to Veteran for local fill." On September 21, 2009, the Veteran was informed he had a positive culture for MRSA. MRSA precautions were explained and he was treated with antibiotics. In a September 2009 addendum it was noted that the Veteran had not quit smoking to date. He claimed he received some patches in the mail "with a bill," of which he was upset with. Please alert ICS when his urine nicotine/cotinine are negative. On September 14, 2009, the Veteran called "extremely angry" because nothing has been done regarding his hands. On September 16, 2009, the "Veteran called - following through with phlebotomy, but hand symptoms not improving. Vet into clinic for reculture of exudates from lesions. Dr. Lacy's note reports the following: Porphyria Cutanea tarda skin lesions. Spoke with veteran on the phone. He has had 3 units of blood removed but still has the skin lesions. Dr Young note [was] reviewed. Possible skin reaction to the hydrocodone. He [was] allergic to codeine and Oxycodone. He did not have as many skin lesions when he was on tramadol but the tramadol did not help the pain he states. susceptible to prescribed antibiotic and notation in chart Vet informed + MRSA. Vet will pick up antibiotics at Mat-Su." Dr. Lacy note this same day: "Rx Septra DS PO BID x 10 days." A September 16, 2009 addendum notes "Porphyria Cutanea tarda skin lesions. Spoke with veteran on phone. He has had 3 units of blood removed but still has the skin lesions. Dr. Young note [was] reviewed. Possible skin reaction to the hydrocodone. He [was] allergic to codeine and Oxycodone. He did not have as many skin lesions when he was on tramadol but the tramadol did not help the pain he stat[ed]. Plan: stop the hydrocodone, try Darvocet N100 for pain; He would seemly react to MS but consider low dose Methadone if Darvon does not help. He states the hydrocodone has not been received in the mail from 9/9/09 refill and the neighbor may have stolen it." On November 17, 2009, the Veteran reports to Mat-Su ER with rib pain and shortness of breath and was diagnosed with rib contusion and pneumonia. He was given a prescription for antibiotics to treat the pneumonia and told to follow-up with his PCP at the VA. Another November 2009 VA treatment record noted MRSA cellulitis/discitis/vertebral osteomyelitis. It was noted that the Veteran was clinically worse on IV vanco had one relapse per family that resulted in him going back into Providence. On November 23, 2009, Mat-Su ER records reflect visit for back pain "like in the past." Note states "has appointment with Dr. Lacy tomorrow." Given pain meds and sent home. On November 24, 2009 VA treatment record reflects: "[w]as seen 11-16-09 for rib contusion. Happened when leaning over fender with pressure on ribs, no fx but felt to be having early pneumonia, did not fill RX for Levaquin due to $$. Went back to 11023 due to increasing low back pain been on multiple different meds. Last PCP note thought [h]e might need to change to methadone for long term care. Denies cough. Low back pain [was] localized to lower lumbar region, no radiation. Insudiuous onset during military service carrying heavy buckets. Also h/o fall from height of 30 feet onto deck ship. Was placed onibuprogen, Percocet and Flexeril w/out relief." He was diagnosed with rib contusion with secondary pneumonia-moxifloxacin 400 mg daily x 1 week; and acute exacerbation of chronic low back pain-will try morphine IR 15 mg q8 hours#30 no rf for local fill. Discuss pruritus related to histamine release and [could] use Benadryl to bock the reaction." He was also to start methadone. On November 28, 2009, he arrived at the Mat-Su ER for incontinent of urine and inability to walk. He was diagnosed with cauda equine syndrome and transferred to Alaska Regional for urgent neurosurgery consult. He was subsequently diagnosed with MRSA pneumonia, MRSA sepsis, and MRSA osteomyelitis of the thoracic spine. He was hospitalized for 6 weeks, including several weeks in a rehabilitation hospital. He had open decubitus ulcers on his back and was wheelchair bound at the time of his release in January 2010. He went on to have additional MRSA osteomyelitis in the lumbar and cervical spine with multiple readmissions through 2010. (See treatment records dated from St. Elias Specialty Hospital and Providence Alaska Medical Center January 2010 to July 2010). A February 2010 VA treatment record noted that the Veteran still had evidence of cavitary pneumonia, his MRI showed T12 collapse with possible extension and /or recurrence of the diskitis, now extending to T9-L4. He also had a wound on his backside, blood cultures were obtained and he was transferred to PAMC for further care. The impression was prior epidural abscess with osteomyelitis, diskitis possible iliopsoas abscess, and anemia of chronic disease. The Veteran was to consult "an infectious disease consult, neurosurgery consult, and sputum blood, cultures, CRP, iron studies, morphine IV, nutrition consult, wound care consult, Lovenox H&P, neurosurgery consult and infectious disease consult sent to HIMS." An April 2010 treatment record noted that the Veteran had ongoing abscess MRSA T12 abscess issues. His treatment plan was a CT guided biopsy, Vanco IV, microscopy to r/o Vanco resistance. The Veteran was advised to quit smoking/ tobacco products, wound consult, MRSA precautions, Infectious Disease consult, likely recommend PECC or St Elias at discharge. A September 2010 VA treatment record notes follow-up for MRSA discitis, cervical cord compression, and MRI findings. The Veteran was to continue on Dilaudid. A September 2010 VA treatment record advised the Veteran that x-rays showed the destruction of disc/bone related to his recent MRSA discitis. It was noted that he was not a surgical candidate unless he gets an emergent condition such as new onset weakness/numbness in arms or legs. A November 2010 VA treatment record noted that the Veteran's had neck problems, dizziness, headaches, and tingling in fingers of both hands. A July 2010 treatment record noted that the MRSA discitis was resolving. An August 2011 VA treatment record noted, in part, blisters on hands. The Veteran stated that he felt that he believed this was where the MRSA started. It was noted that the Veteran was diagnosed with porphyria cutanea tarda in the past. It was also mentioned that the Veteran had a few phlebotomies, but stopped going after one session when the group refused to take blood due to his anemia. The Veteran also noted increased back pain due to severe spinal deterioration from his MRSA infection. The Veteran underwent a VA examination in February 2013. The VA examiner concluded that there was no evidence that the claimed disability was caused by or became worse as a result of the VA treatment in July 2009. He further stated that the additional disability did not result from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending, or VA personnel. And that, nor did any failure on the part of the VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue to progress. He further stated that the additional disability resulted from an event that could not have been foreseen by a reasonable healthcare provider. He stated that the evidence of record revealed he had lesions on his hands that were accurately diagnosed as porphyria cutanea tarda. The definitive diagnosis was delayed due to not receiving the 24 hour urine sample from the Veteran in order to conduct the test for porphyrins. He also stated that the Veteran did not seek treatment for his hands from December of 2008 and June of 2009. In the summer of 2009, the Veteran again presented with hand blisters and completed the 24 hour urine collection allowing for testing of porphyrins in August. The test was positive, confirming the suspected diagnosis and treatment of phlebotomy was started. Prior to this test being completed, the Veteran presented with cellulitis of his hands that was likely due to open lesions being exposed to bacteria in the environment. He was given a prescription for doxycycline on July 24, 2009, which is an agent that is recommended and effective against MRSA. The Veteran had a normal white blood cell count on August 4, 2009 that showed no evidence of infection at that time. When the lesions cultured positive for MRSA in September 2009, he was again appropriately treated with Septra DS (trimethoprim-sulfamethoxazole) for the skin infection. The examiner stated that the delay in definitive diagnosis (the first hand culture was frozen on the way to the lab) did not result in the subsequent sepsis, pneumonia, and bone infections, as the Veteran was appropriately treated with antibiotics that were effective against MRSA both before the definitive diagnosis (doxycycline on 7/24) and at the time of the diagnosis (Septra on 9/21). The onset of MRSA pneumonia in late November 2009 was not due to a delay in diagnosis nor inappropriate treatment. It was most likely due to colonization with MRSA (the Veteran, a known contact, the household) and his susceptibility to pneumonia because of his long history of smoking. The pneumonia led to septicemia (a blood infection) that seeded the bones of his spine with MRSA causing the osteomyelitis. He was treated appropriately, twice, with antibiotics by his VA providers and subsequently developed a wide-spread MRSA infection that could not be predicted. Community-acquired MRSA infections are on the rise, particularly pneumonia. He further stated that the recognition of community-acquired MRSA was in its early stages in 2009/2010. The measures for detection and prevention of disseminated MRSA in the community were not widely recognized at the time of the Veteran's diagnosis in the fall of 2009 as it was not a common cause of pneumonia or sepsis in patients who were not hospitalized, citing, and 1. J Clin Aesthet Dermatol. 2009 April; 2(4): 45-50: Use of Oral Doxycycline for Community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) Infections By Sanjay Bhambri, DO and Grace Kim, DO et, al. The examiner further stated that incision and drainage remained the single most important intervention against CA-MRSA infections, which presented as abscess-like lesions. However, when oral antibiotic therapy was indicated based on the judgement of the clinician, tetracycline agents and trimethoprim-sulfamethoxazole were effective in the majority of patients presenting with uncomplicated SSTIs caused by CA-MRSA, and were commonly recommended. Id.; (citing Tetracyclines are effective against many 2. J Glob Infect Dis. 2010 Jan-Apr; 2(1): 49-56). He further stated, in part, that the epidemiology of MRSA was changing and the origin of these bacteria remains unknown. The examiner stated that the Veteran presented with cellulitis of the hands that was likely due to open lesions being exposed to bacteria in the environment in July 2009. He completed the 24 hour urine collection required for testing of porphyrins. He was then prescribed doxycycline in July of 2009. He had a normal white blood cell count on August 4, 2009 that showed no evidence of infection at that time. When the lesions cultured positive for MRSA in September of 2009, the Veteran was appropriately treated with Septra DS ((trimethoprim and sulfamethoxazole) for the skin infection. The examiner further stated that the delay in definitive diagnosis did not result in the subsequent sepsis, pneumonia, and bone infections, as he was appropriately treated with antibiotics that were effective against MRSA both before the definitive diagnosis and at the time of the diagnosis. The examiner concluded that the onset of MRSA and pneumonia in late November 2009 was not due to a delay in diagnosis nor inappropriate treatment. It was most likely due to colonization with MRSA and susceptibility to pneumonia because of his long history of smoking. The pneumonia led to septicemia, a blood infection, which seeded the bones of the spine with MRSA causing the osteomyelitis. He stated that the Veteran was treated appropriately, twice, with antibiotics by VA providers and subsequently developed a wide-spread MRSA infection that could not have been predicted. The Veteran was flown to Seattle to be evaluated by a spine specialist in February of 2009. The specialist stated he would be willing to provide surgical intervention only if the Veteran was able to discontinue smoking as it would interfere with wound healing. The Veteran never had the surgical intervention, as he continued to smoke and became ill with MRSA sepsis in the fall of 2009. Thus, the outcome of the Veteran's claim for 38 U.S.C.A. § 1151 rests on whether the additional disability was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of VA fault, or was the result of an event that was not reasonably foreseeable. In determining whether a Veteran has an additional disability due to VA medical care, VA compares the Veteran's condition immediately before the beginning of the relevant care or treatment to the Veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, evidence must show that the VA medical treatment resulted in the Veteran's additional disability or death. Merely showing that a Veteran received care, treatment, or examination and has additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). The proximate cause of disability is the action or event that directly caused the death, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). Additional disability or death caused by a Veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(3). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability or death, it must be shown that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) that VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1); see also VAOPGCPREC 5-01. The Veteran has not satisfied the requirements of a causal relationship between the MRSA and VA medical treatment and fault on the part of the VA or that the disability was an event not reasonably foreseeable. Simply, the Veteran had a history of a skin condition, which was treated for presumptive MRSA cellulitis with multiple different courses of antibiotics. The Veteran smoked a 1/2 pack cigarettes per day and drank beer on a daily basis. (See 12/09 Treatment Records from St. Elias Hospital). He subsequently became progressively worse and was diagnosed with bacteremia consistent with MRSA on September 21, 2009. He was also eventually to have multiple septic emboli with a paravertebral abscess, epidural abscess, vertebral osteomyelitis and diskitis, as well as multiple septic emboli to the lungs and an 8th rib erosion and associated mass. He was started on high dose vancomycin and had a T12-toL3 laminectomy. Immediately following surgery there was evidence of severe sepsis and respiratory failure. Specifically, the preponderance of the evidence is against a finding that there was a causal relationship between the VA medical treatment provided and the Veteran's MRSA and competent medical evidence established that there was no fault on the part of VA in the treatment provided or that the disability was an event not reasonably foreseeable. The most probative evidence of record, the February 2013 VA examination report, concluded that it was less likely that the MRSA infection was due to carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA, or due to an event that was not reasonably foreseeable. The opinion was based on a full review of the record, including the Veteran's statements and a thorough clinical evaluation with cited references to medical literature. Bloom v. West, 12 Vet. App. 185 (1999). The Veteran has not provided any medical opinion to the contrary. The Veteran's statements regarding his VA treatment are of no probative weight and he was prescribed multiple different antibiotics. He was not compliant with medical directives when he continued to smoke and drink affecting the wound healing process. There is no indication in the record, nor has the Veteran alleged, that the VA treatment records are incomplete. His VA treatment records accurately document the history of the Veteran's treatment at VA. See Mindenhall v. Brown, 7 Vet. App. 271 (1994) (regarding the applicability of the presumption of regularity to RO actions). Although lay persons are competent to provide opinions on some medical issues, the specific disability in this case - MRSA infection - and the question of treatment negligence fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). They are complex medical issues that require specialized training for a determination as to diagnosis and causation, and they are not susceptible of lay opinions on the question of negligence, carelessness, etc. Therefore, the Veteran's statements cannot be accepted as competent evidence sufficient to establish entitlement to benefits pursuant to 38 U.S.C.A. § 1151. Accordingly, the most probative evidence in this case is the VA opinion which reflects that the VA acted with reasonable care and due diligence in treating the Veteran. Therefore, a grant of disability benefits under the provisions of 38 U.S.C.A. § 1151 for residuals of MRSA infection is not warranted. ORDER Entitlement to compensation under 38 U.S.C. 1151 for residuals of MRSA is denied. ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs