A comatose man who once served his nation died after being turned away from a veterans medical center in Gainesville, Florida, because an ambulance crew that brought him had no proof that he was a veteran.
The incident at the Malcom Randall VA Medical Center was investigated by the Veterans Administration’s Office of the Inspector General, which issued a report last week condemning what took place.
The incident took place in the summer of 2020, according to the May 31 report. The veteran was suffering from heart failure.
The unidentified man (60) 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 ..https://t.co/V0dufbBZMQ
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“During transport, EMS personnel conveyed the patient’s initials and a contact number for a family member, and informed facility staff that they did not have any other patient identifying information. Facility staff, including four nurses, met the EMS responders at the Emergency Department ambulance bay and again requested the patient’s identification information,” the report stated.
The report chronicled the cold, hard facts of what took place as the veteran lay without treatment, suffering from septic shock, pneumonia, and large, open wounds on his legs.
“Later, at the request of one of the nurses, an Administrative Officer of the Day joined the nurses to request identifying information to verify the patient was an eligible veteran. The EMS responders reiterated they were unable to provide additional identifying information,” the report stated.
(The man was, in fact, “later verified to be an eligible veteran,” the report stated.)
Does the VA give good care to our veterans?
“After waiting for a period of time in the ambulance bay, without facility staff attending to the patient, EMS responders asked if they should take the patient to Shands and facility staff responded ‘yes.’ EMS then reloaded the patient into the ambulance and transported the patient to Shands where the patient died later that day,” the report said.
Shands is a hospital affiliated with the University of Florida, directly across the street from the medical center, according to the report.
The report condemned the personnel who turned away a veteran.
“The OIG determined that facility Emergency Department nurses failed to provide emergency care to a patient who arrived at the facility by ambulance,” the report stated.
“Despite having been informed of the limited patient identifying information EMS personnel had received prior to arrival, Emergency Department nurses and an Administrative Officer of the Day wasted critical time by continuing to concentrate efforts on patient identification versus patient care,” the report stated.
“The Emergency Department nurses’ failure to prioritize medical intervention resulted in EMS personnel reloading the patient into the ambulance for transport to Shands where the patient died approximately 10 hours after admission.”
Noting that all who cared for the patient with the exception of the VA hospital staff identified his “critical medical condition,” the report stated the VA hospital’s “Emergency Department nurses disregarded the EMS personnel’s patient status report, failed to recognize the patient’s emergency medical condition, and inaccurately assessed the patient’s condition as less critical.”
No one lost a job over it.
“Although nursing and administrative staff were issued proposed removals, the Facility Director rescinded the removals and issued written warnings,” the report stated, noting that the director relied on information that was in dispute and “potentially compromised patient safety in the Emergency Department.”
Although names are not used, the OIG report said that the veteran who died was 60 years old.
On the day of the incident, according to the report, a neighbor had found the veteran unresponsive and called an ambulance. The neighbor told the ambulance crew that the man had recently been discharged from a VA hospital, the report said.
One nurse said, “the patient was moaning constantly and appeared to be in pain.”
The report noted that a security guard at the facility told the investigators that during the time the veteran was kept waiting, hospital staff were arguing with first responders, while other staff were insisting that the hospital had a duty to provide treatment, regardless of whether the man’s service status.
“The contract security guard recalled facility staff arguing with the EMS personnel stating that if they could not obtain the patient’s information, and determine veteran status, then they could not take the patient,” the report said.
The report also raised questions about the competency of the medical center’s nursing staff and its documentation.
“Facility policy requires nursing staff competency to be verified three times annually and prior to performing care. Competencies are to be maintained and documented in employee competency folders,” the report states.
“The OIG identified deficiencies in the completion, validation, and oversight of Emergency Department nurse competencies,” the report stated. “Specifically, a review of selected Emergency Department nurse competency folders revealed that some Ongoing Competency Assessments were incomplete and individual competencies were not validated. Further, the OIG found a lack of oversight measures for Emergency Department nurse competencies.”
The report’s conclusion was stark:
“The OIG determined that facility Emergency Department nurses failed to provide emergency care to a patient who arrived at the facility by ambulance,” its opening paragraph reads. “Despite having been informed of the limited patient identifying information EMS personnel had prior to arrival, Emergency Department nurses and an [Administrative Officer of the Day] wasted critical time by continuing to concentrate efforts on patient identification instead of focusing on patient care. The Emergency Department nurses’ failure to prioritize medical intervention resulted in EMS personnel reloading the patient into the ambulance and transporting the patient to Shands where the patient died approximately 10 hours after admission.”
It also included five recommendations, including making sure nursing competencies certifications are up to date and takes actions to avoid a repeat of the 2020 incident.
Recommendation No. 2 might be the one most non-medical personnel can relate to:
“The Malcom Randall VA Medical Center Director ensures that Emergency Department nurses and Administrative Officers of the Day prioritize patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.”
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