Emergency room staff at a Department of Veterans Affairs hospital in Florida violated policy by refusing to care for a veteran dying of heart failure because they could not confirm his military service, the VA's watchdog said in a new report this week.
The unidentified 60-year-old man died 10 hours later after being taken to a different hospital. The VA inspector general faulted staff at the Malcom Randall VA Medical Center in Gainesville for having "wasted critical time" by continuing to try to identify the man and not prioritizing immediate medical treatment.
"Emergency Department nurses dismissed the reported criticality of the patient's condition based on their own inaccurate visual assessment of the patient and the primary focus on verifying the patient's eligibility status," the inspector general, or IG, said in a report released Tuesday.
While facility leaders have taken actions to address issues identified in an initial investigation, the IG warned that "there continues to be a delay in the provision of emergency care to patients in the Emergency Department due to inefficient registration processes and practices."
The incident the report focused on happened in summer 2020, but the IG said that during the course of its investigation it discovered "similar patient incidents" in 2019.
The man in the summer 2020 incident had previously been treated at the same VA medical center for heart issues that spring.
When a neighbor found the man unresponsive that summer, they called an ambulance and told the emergency responders that he had recently been discharged from a VA hospital.
En route to the VA, the ambulance personnel notified hospital staff of the man's critical condition and gave them what little identifying information they had, including his initials and contact information for a family member, but told dispatchers they could not get any more identification since the patient was unconscious.
But when the ambulance arrived, nurses and an administrator requested more identifying information. After waiting in the ambulance bay "for five to 10 minutes," the emergency responders asked whether they should take the man to another hospital, and the VA staff replied "yes," according to the IG report.
Under federal law, hospitals with emergency departments are required to "to provide medical screening examinations and stabilizing treatment to patients with emergency medical conditions." The VA isn't formally subject to that law, but its policy is still to comply with it and provide "emergency care to veterans, staff and other non-veterans who experience a medical emergency while in or near a VA facility," according to the IG report.
Because of the incident, the IG questioned "nurses' competence to treat patients seeking emergency care" and found "deficiencies in the completion, validation, and oversight of Emergency Department nursing competencies and competency folders."
Further, the facility director decided not to fire anyone over the incident and instead issued written warnings, which "potentially compromised patient safety in the Emergency Department," the IG added.
The IG issued several recommendations, including that the facility "prioritize patient care before patient eligibility status" and ensure that nurses' training is up to date and complete. The IG also recommended an internal review to determine whether any further disciplinary action is warranted and following through on several action plans that stemmed from the incident. In a response included in the report, the facility pledged to follow all the recommendations.
In a written statement Wednesday, a spokesperson for the North Florida/South Georgia Veterans Health System said it "values the recommendations of the VA's Office of Inspector General."
"We embrace high reliability and are committed to zero harm for our patients. As outlined in the response, action plans have been completed or are currently under implementation," spokesperson Melanie Thomas said. "We remain dedicated to honoring our Nation's Veterans by ensuring a safe environment and delivering exceptional health care through continuously improving our standards."