Citation Nr: 1602483 Decision Date: 01/21/16 Archive Date: 01/28/16 DOCKET NO. 02-20 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of a Staphylococcus infection following coronary artery bypass grafting (CABG). REPRESENTATION Veteran represented by: James G. Fausone, Esq. WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Moore, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In September 2004, the Board remanded the claim for additional development. In a March 2008 decision, the Board denied the Veteran's claim. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In March 2009, the Court issued an order granting a February 2009 Joint Motion for Remand (JMR). In June 2010, and April 2013, the Board remanded the claim for additional development. In April 2003, the Veteran presented sworn testimony during a video conference hearing in Jackson, Mississippi, which was chaired by the undersigned. A transcript of the hearing has been associated with the Veteran's claims file. This appeal was processed using the VBMS and Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT The Veteran does not have an additional disability, to include residuals of a Staphylococcus infection following CABG, that is the result of 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 additional disability was an event which was not reasonably foreseeable. CONCLUSION OF LAW The criteria for entitlement to VA compensation under 38 U.S.C. § 1151 for residuals of a Staphylococcus infection following CABG have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2014 & Supp. 2015); 38 C.F.R. §§ 3.102, 3.361 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran seeks entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for residuals of a Staph infection following CABG performed at the VAMC in New Orleans, Louisiana in June 1999. He argues that he developed a postoperative infection as a result of unsanitary conditions in the ICU upon his readmission. Specifically, he claims that the ICU was undergoing construction and that there was dust throughout the unit and no hot water. Section 1151 compensation is awarded for qualifying additional disability in the same manner as if such additional disability were service-connected. The purpose of the statute is to award benefits to those veterans who were disabled as a result of VA treatment, VA surgery, or vocational rehabilitation. 38 U.S.C.A. § 1151(a) (West 2014 & Supp. 2015). For purposes of establishing entitlement to section 1151 benefits, a disability or death is a qualifying additional disability or qualifying death if the disability or death: (1) was not the result of the Veteran's willful misconduct; and (2) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary, either by a Department employee or in a Department facility as defined in section 1701(3)(A) of this title, and the proximate cause of the disability or death was - (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151(a) (West 2014 & Supp. 2015); 38 C.F.R. § 3.361(a)-(d) (2015). First, there must be evidence of additional disability, as shown by comparing the Veteran's condition before and after the VA medical care in question. 38 C.F.R. § 3.361(b) (2015). VA considers each body part or system separately. The additional disability must not be the result of the Veteran's willful misconduct. 38 U.S.C.A. § 1151(a) (West 2014 & Supp. 2015); 38 C.F.R. § 3.301(c)(3) (2015). Second, the additional disability must be caused by hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program furnished the Veteran by VA. 38 C.F.R. § 3.361(c) (2015). Merely showing that a Veteran received care, treatment, or examination and that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1) (2015). In order for additional disability to be compensable under 38 U.S.C.A. § 1151, the additional disability must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. 38 C.F.R. § 3.361(c)(1) (2015). Additional disability 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) (2015). Third, with regard to causation, the proximate cause of the disability, as opposed to a remote contributing cause, must be 1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or 2) an event that was not reasonably foreseeable. 38 U.S.C.A. § 1151(a)(1) (West 2014 & Supp. 2015); 38 C.F.R. § 3.361(d) (2015). With regard to carelessness or negligence, 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 was the proximate cause of a Veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(1) (2015). Minor deviations from those requirements that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Id. Consent may be express (i.e., given orally or in writing) or implied under the circumstances specified in § 17.32(b) of this chapter, as in emergency situations. Id. With regard to reasonable foreseeability, whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined 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 health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2) (2015). But if the Board makes an initial determination that any additional disability was not caused by VA, the Board is not required to make a finding as to whether the event in question was reasonably foreseeable. See 38 C.F.R. § 3.361(c) (2015); Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005). Thus, section 1151 contains two causation elements - a Veteran's disability must not only be "caused by" the hospital care or medical treatment he received from VA, but also must be "proximate[ly] cause[d]" by the VA's "fault" or an unforeseen "event." See 38 U.S.C.A. § 1151(a)(1) (West 2014 & Supp. 2015). In determining whether § 1151 compensation is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2014 & Supp. 2015); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In order for additional disability to be compensable, it must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005). The additional disability must have been the result of injury flowing directly from the actual provision of care, treatment, or examination furnished by VA. Loving, 19 Vet. App. at 101. The mere fact that a claimant is harmed by an event that occurs coincidentally with VA care, treatment, or an examination is not sufficient to establish causation. Mangham v. Shinseki, 23 Vet. App. 284, 287 (2009). The relevant issue is whether VA's direct actions caused harm. Id. at 289. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The record reflects that the Veteran presented to the New Orleans VAMC on June 17, 1999, to undergo coronary artery bypass grafting (CABG) times two. His operative report did not reflect any complications. The first two days following his operation were reported as unremarkable. On the 3rd post-operative day, his chest wound was noted to have scant serosanguinous discharge that was resolving. His antibiotics were discontinued. He was discharged on June 23, 1999. At that time, he was advised to return to the emergency room for any fever, increased drainage from his sternum, redness, soreness, or increasing shortness of breath. On June 25, 1999, the Veteran presented to the Hancock Medical Center emergency room with complaint of coughing and bleeding at his surgical site. He stated that the symptoms started that day. Notably, he denied a history of smoking cigarettes following his heart surgery. He was transferred to the New Orleans VAMC for further evaluation of sternal wound dehiscence. The Veteran was admitted to the New Orleans VAMC on June 25, 1999 wherein he underwent irrigation and debridement (I&D) of the sternal mediastinal wound. Tissue and bone samples were sent to the laboratory for cultures. Two days later, a culture returned positive for coag-negative Staph. The affected tissue was surgically removed along with all sternal wires. A subsequent consultation with the Plastic Surgical Service recommended further sternal wound debridement with primary closure to which the veteran's spouse consented. On June 29, 1999, the Veteran underwent debridement of the sternum bone and surrounding muscles with sternal wound closure utilizing bilateral pectoralis advancement flaps. Thereafter, laboratory testing performed by VA identified a candida infection of the sternal wound. On July 15, 1999, the Veteran underwent debridement of sternal chest wound involving resection of nonviable fat and skin down to the pectoralis flap. On July 20, 1999, he underwent an I&D of avascular necrotic tissue of the right upper rectus. On July 27, 1999, the Veteran underwent another surgical procedure for definitive closure of the rectus flap. The procedure involved right rectus flap rotation, supercharged to the internal mammary and vein vessels, split-thickness graft and debridement of the sternal wound. A VA examination in September 2002 found the Veteran to have a large chest and abdominal scar from complications of coronary bypass graft and a history of sternal dehiscence with subsequent infections. However, the examiner stated that it was not possible to render an opinion as to the presence of any negligence, stating that the institution involved should address the question. The examiner stated that additional opinions should be obtained, if required, from a general surgeon, orthopedic surgeon, or neurologist. In October 2006, the Acting Director of the Southeast Louisiana Veterans Health Care System provided the following statement: a. The New Orleans VAMC was under construction/renovation in 1999. Specific areas affected were as follows: (1) Ward 5B - This inpatient ward was completed in early 1999 and activated on May 4, 1999 following a total gut and renovation to provide for no more than two patient bedrooms with private and semi-private baths. The primary issue that arose with this project was insufficient hot water for the new showers. (2) 1D Primary Care Clinic - In construction in September 1999. (3) 8th Floor - This inpatient mental health ward was under construction throughout 1999. This was a total gut and renovation to provide for no more than two patient bedrooms with private and semi-private baths. (4) Ward 7B - This inpatient ward was under construction throughout 1999 following a total gut and renovation to provide for no more than two patient bedrooms with private and semi-private baths. (5) Ward 6C - This ICU ward was a total gut and renovation that doubled the space of the SICU and provided proper privacy as well as improved efficiency. This project began in the fall of 1999. (6) Primary Care Center, 3rd Floor - project occurring in 1999 which renovated old inpatient space into ambulatory care exam rooms. (7) Ambulatory Care Surgery Unit 6B - expanded capacity from 4 to 10 beds and was completed prior to July 1999. b. All construction areas were secured. There was no patient care in these areas. c. Gowns, masks and gloves were available and there was no restriction on their issue in the intensive care unit areas. d. During 1999, it is known that some patient rooms had problems with sufficiency or temperature of domestic hot water. In January 2007, a VA thoracic surgeon reviewed the contents of the veteran's claims folder. After specifically acknowledging review of the statements from the veteran, his witnesses, and VA's Acting Director, concerning the construction and renovation of the New Orleans VAMC, the examiner provided the following opinion: ... A review of the preoperative assessment, operative record, and postoperative care shows that it meets the standard of care. [The Veteran's] operative procedure took approximately three hours and had no intraoperative complications. There is nothing in the record to talk about any problems in the Operating Room concerning construction and the nurse's notes do not reflect any problems in the Operating Room. There is also his discharge dictation that I reviewed showed that he had a normal postoperative course and the ICU care was deemed appropriate. I did not find any reference to the cleanliness or problems within the ICU care in the immediate postoperative period. His antibiotics were appropriately managed. I did not see that his glucose was significantly elevated during the perioperative period. The patient was then discharged on the twenty-third and was in stable condition with his wounds healed appropriately. He did develop a postoperative wound infection while at home which required return to the New Orleans VA and a number of surgeries to repair this sternal wound infection. His sternal wound infection was a common occurrence in postoperative CABG's in approximately 2-10% of coronary artery bypass surgeries. At that time it was not recognized that placing the patient on a glucose infusion drip for elevated glucoses could prevent this type of complication and this was not performed in the postoperative period. However, the perioperative antibiotics and the operative care for that time were very appropriate. His wound infection led to subsequent events that occurred later and almost all of the patient complaints occurred in the postoperative period after he had his sternal infection and I do not see where this contributed to the original event which was the sternal wound infection. Therefore, I cannot, on the basis of what I see here, say that the sternal wound infection was an error in skill, judgment or any fault on the New Orleans VA Medical Center for his immediate perioperative care. There appears to be significant issues with potential for less than adequate environment after the wound infection occurred with some potential for inability for the patient to adequately be bathed and some health care issues concerning the cleanliness of the rooms in the postoperative period after his wound was opened and the grafts in his plastic reconstruction. But his original event does not appear to be related to this. He ultimately healed from this, and thereby the outcome of his plastic reconstruction appears to be excellent considering the potential for major infectious complications for his reconstruction. So in summary, I do not see where there is evidence that the sternal wound infections experienced by the veteran in June- August 1999 were the result of carelessness, negligence, lack of proper skill or error in judgment on the part of the New Orleans VA Medical Center. The Board finds that the Veteran's claim for §1151 compensation must be denied. 38 U.S.C.A. § 1151(a); 38 C.F.R. § 3.361(a)-(d). As an initial matter, the evidence shows that VA CABG surgery in June 1999 did in fact cause additional disability to the Veteran's chest. See 38 C.F.R. § 3.361(b), (c). This is shown in the VA treatment records and lay statements. A September 2002 VA examination, and the January 2007 VA opinion, also note such. However, the issue is whether the proximate cause of additional disability to the chest is either: 1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the left eye surgeries; or 2) an event that was not reasonably foreseeable. See 38 U.S.C.A. § 1151(a)(1); 38 C.F.R. § 3.361(d). With regard to the issue of carelessness and negligence, VA treatment records, and the January 2007 VA physician's opinion, do not establish that VA failed to exercise the degree of care that would be expected of a reasonable health care provider. See 38 C.F.R. § 3.361(d)(1)(i). The only competent opinion on this issue is the January 2007 opinion from the VA medical expert, who determined that there was no evidence of carelessness, negligence, skill deficit, or erroneous judgment on the part of the VA cardiac surgeons. The Board finds that this opinion is considered to be highly probative evidence against the claim, as the physician based the opinion on a review of the Veteran's claims file, and as the opinion is accompanied by a sufficient explanation. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no competent medical opinion that contradicts this opinion. In reaching this decision, the Board has considered the statements of the Veteran and his family members, friends, and attorney. Although laypersons, such as the Veteran and his family members, friends, and attorney, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making definitive determinations as to clinical decisions and foreseeable complications based on knowledge of cardiac surgery. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran and his representative have no such expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also 38 C.F.R. § 3.159 (a)(1). In February 2009, a Joint Motion (JMR) indicated that the issue of informed consent had not been adequately addressed. VA regulations provide that informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient of the proposed diagnostic or therapeutic procedure or course of treatment the expected benefits, reasonably foreseeable associated risks, complications, or side effects, reasonable and available alternatives, and anticipated results if nothing is done. 38 C.F.R. § 17.32(c) (2015). Under 38 C.F.R. § 17.32(d), the informed consent process must be appropriately documented in the medical record. In addition, signature consent is required for all diagnostic and therapeutic treatments or procedures that require the use of sedation, anesthesia or narcotic analgesia; are considered to produce significant discomfort to the patient; have a significant risk of complication or morbidity; or require injections of any substance into a joint space or body cavity. Id. The presumption of regularity may not be used to conclude that a physician has fully informed a veteran about a particular consequence of a particular medical procedure where the only evidence supporting the presumption is a generic consent form that was filled out properly. McNair v. Shinseki, 25 Vet. App. 98, 104-107 (2011). A physician's failure to advise a veteran of a foreseeable risk may be considered "a minor, immaterial deviation" if it is determined that "a reasonable person in similar circumstances would have proceeded with the medical treatment even if informed of the foreseeable risk." Id. The Court held that even if a reasonably foreseeable risk was not disclosed, it can be considered a minor, immaterial deviation under the regulation if a reasonable person in similar circumstances would have proceeded with the medical treatment even if informed of the foreseeable risk. Id. at 102. In Halcomb v. Shinseki, 23 Vet. App. 234 (2009), the Court held that the veteran did not establish lack of informed consent before eye surgery as the basis for entitlement to compensation benefits for loss of vision of the eye under 38 U.S.C.A. § 1151 based solely on failure of consent documents to list specific disclosed risks. The failure to specifically specify which risks were reasonably foreseeable results of a medical procedure, and instead providing simply a generic informed consent form, was not negligence per se. The Court found that a generic informed consent form was adequate, because the veteran in that case had not objected to the content of the informed consent that had been provided. A review of the file includes June 1999 Informed Consent for a "Coronary Artery Bypass Graft with Transfusion of Blood/Blood Products." The Veteran signed the form indicating that he understood the nature, risks, and expected results of the procedure. The surgeon also signed the form indicating that he had explained the risks of the procedure to the Veteran. An associated progress note stated that the Veteran had "decision-making capacity," and that consent was obtained. The Veteran underwent the procedure on June 17, 1999 without complications and was discharged from the VAMC on June 23, 1999. After two days at home, the Veteran had a coughing spell that caused his surgical wound to reopen. He was taken to a private emergency room, then transferred to the New Orleans VAMC. At that time, he was noted to have an infection and underwent multiple surgeries to treat the infection and has been left with residuals, including a large scar of the chest. The Board finds that VA health care providers complied with the informed consent requirements of 38 C.F.R. § 17.32 prior to the Veteran's June 1999 VA CABG. See 38 C.F.R. § 3.361(d)(1)(ii). The evidence shows that Veteran's consent was obtained. The informed consent forms indicate that the physician discussed the nature of the CABG, potential risks, and the likely results. Although the risks were not specifically enumerated on the forms, there is no indication that the risk of postoperative infection was not discussed, nor does the Veteran argue such. The informed consent form is found to be sufficient under the law, as it was signed by the Veteran, and doctor, prior to the surgery in issue, following a consultation specifically about the surgery. The Board therefore finds that the evidence shows that the procedures at 38 C.F.R. § 17.32 were satisfactorily complied with, and that the Veteran's informed consent is shown to have been obtained. 38 C.F.R. § 3.361; McNair; Halcomb. With regard to the issue of reasonable foreseeability, the standard for foreseeability is what a "reasonable health care provider" would have considered to be an ordinary risk of treatment that would be disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. Merely because a treating physician, expert, or other health care provider actually foresaw certain risks does not mean that a reasonable health care provider with primary care for the patient would have disclosed these risks. The test to apply is how a reasonable health care provider would behave if asked to perform a certain procedure on a veteran with the same characteristics as the veteran in a given case. Schertz v. Shinseki, 26 Vet. App. 362, 369 (2013). The Board finds that it is not shown that the proximate cause of the Veteran's additional chest disability was an event "not reasonably foreseeable." See 38 C.F.R. § 3.361(d)(2). The evidence shows that the Veteran's complications from his VA CABG were foreseeable ones. In this regard, the January 2007 VA physician indicated that infection is a risk inherent in any surgery, and stated that as many as 10 percent of patients undergoing CABG experienced sternal wound infection postoperatively. He further stated that the complications that the Veteran encountered are a "common occurrence" in postoperative CABG. The record therefore indicates that the Veteran's demonstrated complications from his VA heart surgery were clearly foreseeable. There is no contrary medical opinion of record on that issue. The evidence of record thereby reflects that a "reasonable health care provider" would have considered the specific complications shown by the Veteran to be ordinary risks of treatment. Schertz. In summary, the Veteran's demonstrated residual symptoms were foreseeable complications of his VA cardiac surgery. Because it is found that informed consent was provided and that postoperative sternal wound infection was a reasonably foreseeable result of the CABG surgery, the Board does not need to proceed to the question of whether a reasonable person would have proceeded with the surgery. McNair. Given the foregoing, the claim of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for residuals of a Staphylococcus infection following CABG must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b) (West 2014 & Supp. 2015); 38 C.F.R. § 3.102 (2015); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a) (2015). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. In letters, dated in November 2001 and November 2004, VA provided all required notice elements, including what evidence VA would seek to obtain and what evidence the Veteran was expected to provide and what was required to establish entitlement to compensation under 38 U.S.C.A. § 1151, and information regarding disability ratings and effective dates. 38 U.S.C.A. § 5103(a) (West 2014 & Supp. 2015); 38 C.F.R. § 3.159(b) (2015); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board notes that the above letters did not inform the Veteran of how VA determines the appropriate disability rating and effective date to be assigned when a claim is granted. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). However, as the Board has concluded that the preponderance of the evidence is against the claim for compensation under 38 U.S.C.A. § 1151, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. VA's duty to assist has also been satisfied. VA treatment records and the VA examination/medical opinion have been associated with the claims file. Private treatment records have been obtained to the extent possible. The Veteran has not identified any outstanding relevant private or other treatment records. An opinion was obtained from a VA physician in January 2007. The opinion involved a review of the claims file, consideration of the Veteran's lay statements/history, and conclusions that were supported by sufficient rationale. The opinion is more than adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The claim was remanded to the Agency of Original Jurisdiction (AOJ) in most recently in April 2013 for additional evidentiary development including associating the Veteran's signed informed consent for his June 1999 CABG with the claims file. The AOJ obtained the identified consent form and associated it with the claims file. The AOJ then readjudicated the claim in a December 2014 supplemental statement of the case. Accordingly, all remand instructions issued by the Board have been substantially complied with and this matter is once again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In April 2003, the Veteran was afforded a videoconference hearing. An individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Those duties were met here. During the Veteran's hearing, the issue on appeal was identified. Information was also elicited from the Veteran concerning his post-surgical chest disability and his contentions regarding its etiology. There was also discussion relating to the Veteran's contentions regarding the cleanliness of the New Orleans VA Medical Center (VAMC) at the time of his initial surgery. Significantly, the Veteran's hearing testimony was the reason for the Board's September 2004 remand to obtain additional information on the state of the New Orleans VAMC in 1999. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). ORDER Entitlement to VA compensation under 38 U.S.C. § 1151 for residuals of a Staphylococcus infection following CABG is denied. ____________________________________________ T. STEPHEN ECKERMAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs