Citation Nr: 1339103 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 10-40 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for chronic deep sacral ulcers as a result of treatment at the St. Louis VA Medical Center (VMAC) from March 12, 2008 to May 19, 2008. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Avery M. Schonland, Associate Counsel INTRODUCTION The Veteran had active service from July 1971 to July 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) St. Louis, Missouri. In deciding this appeal, the Board has reviewed the Veteran's electronic (Virtual VA) file, in addition to his physical claims file. Virtual VA is a highly secured electronic repository used to store and review every document involved in the claims process. VA also is in the process of transitioning to an even newer electronic medium, the Veterans Benefits Management System (VBMS). In this case, there are additional records relating to the Veteran's pension benefits and additional treatment records from the St. Louis and Kansas City VA Medical Centers (VAMC) among the Veteran's paperless records in Virtual VA. There are no additional records in VBMS. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran seeks compensation under the provisions of 38 U.S.C.A. § 1151 for chronic deep sacral ulcers, as he contends that he developed these ulcers while he was an inpatient at the St. Louis VAMC for a colonoscopy from March to May 2008. The record reflects that during this hospitalization he suffered an abrasion during the colonoscopy, fell while getting out of bed without injury, and developed a decubitus ulcer on his coccyx in March 2008. The ulcer completely healed prior to discharge in May 2008. The record also reflects that following his March 2008 colonoscopy, the Veteran developed a large stage IV sacral pressure ulcer during an episode of septic arthritis of the left knee in May 2009. This ulcer became septic, and the Veteran was again hospitalized to treat the ulcer in May 2009. In December 2009 the RO obtained a medical opinion in connection with this claim. The examiner noted definite evidence of chronic deep sacral ulcers, but felt that this was not a reasonably foreseeable development; and found no negligence on the part of the St. Louis VAMC healthcare providers. He also reviewed the Veteran's claims file, and commented on the lack of treatment records for the period between the 2008 hospitalization and the 2009 hospitalization. This opinion failed to discuss the foreseeability of pressure ulcers in light of the Veteran's status as a tetraplegic patient. He also omitted any discussion of the St. Louis VAMC's negligence or error in judgement in failing to place the Veteran on a program aimed at preventing pressure ulcers, or in the treatment of the ulcer once it developed given the lengthy healing time. Further, the VA examiner did not explain whether the Veteran's 2009 large stage IV sacral pressure ulcer could be related to, or a subsequent manifestation of, his 2008 decubitus ulcer on coccyx. This opinion, is therefore inadequate. Once the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board therefore finds that another VA examination and medical opinion is necessary. Finally, the record reflects that the Veteran receives treatment through the Kansas City and St. Louis VAMCs. On remand the RO/AMC should obtain any outstanding treatment records prior to performing the necessary VA examination. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should associate with the Veteran's claims file any outstanding treatment records from the Kansas City and St. Louis VAMCs; specifically for treatment between May 2008 and May 2009, and since December 2009. 2. After any outstanding VA treatment records have been obtained, schedule the Veteran for a VA examination. The examiner should review the claims file in conjunction with the examination, and should opine as to whether: a. The Veteran currently has any manifestation of the decubitus ulcer on coccyx or large stage IV sacral pressure ulcer; b. If the development of such pressure ulcers is a reasonably foreseeable development in tetraplegic patients; c. If the failure to place tetraplegic patients on a program to prevent pressure ulcers represents carelessness, negligence, lack of proper skill, error in judgement, or similar instance of fault on the part of the St. Louis VAMC healthcare providers; d. If the Veteran's slow healing of the decubitus ulcer on coccyx in March 2008 was due to any carelessness, negligence, lack of proper skill, error in judgement, or similar instance of fault on the part of the St. Louis VAMC healthcare providers; and e. If the Veteran's May 2009 large stage IV sacral pressure ulcer, or any current pressure ulcer, is related to the 2008 decubitus ulcer of the coccyx or is otherwise related to any carelessness, negligence, lack of proper skill, error in judgement, or similar instance of fault on the part of the St. Louis VAMC healthcare providers from March through May of 2008. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim on appeal. If the benefits sought on appeal are not granted in full, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).