Nursing staff at a Florida VA emergency room refused to admit a veteran dying of septic shock and heart failure because they could not confirm his military service, investigators concluded in a new report. The patient, an unidentified 60-year-old man, died 10 hours later at a different emergency room.
The Department of Veterans Affairs Office of Inspector General (OIG) blasted staff at the Malcom Randall VA Medical Center in Gainesville, Florida, for continued policy violations and inefficient processes in the report, which was published Tuesday, May 31.
“[Emergency Department staff] wasted critical time by continuing to concentrate efforts on patient identification versus patient care,” the OIG wrote. The OIG also warned that, while the facility had implemented changes brought about by an initial report, there were still delays in care due to “inefficient registration processes and practices.”
The veteran, who is not identified in the report, was taken to the hospital by EMS personnel during the summer of 2020 after a neighbor discovered the man unresponsive.
A paramedic spoke to emergency room nursing staff by radio while en route to the VA facility, informing them that the patient had large open wounds on both legs and feet and might be suffering from sepsis. The paramedic also said the patient was unresponsive, making incomprehensible sounds, struggling to breathe, and had a Glasgow Coma Scale score of eight. According to the OIG, a GCS score of eight almost always means that immediate intubation is necessary.
A nurse asked for the patient’s “identifiers,” and the paramedic provided all known information, including the patient’s initials and a family contact number, according to the report.
“And we’re sure he’s a veteran?” the nurse asked, according to the OIG’s review of EMS audio recordings. The paramedic responded that a neighbor told them the patient had been discharged from the VA facility a few weeks prior.
While the patient was still in transport, nursing staff continued to ask dispatchers for more information to confirm the patient’s identity and status as a veteran, with dispatchers maintaining that EMS could not obtain more information because the patient was unconscious.
When the man arrived at the VA facility, emergency room staff told EMS responders they could not accept the patient without more identifying information. EMS responders eventually put the man back into the ambulance and took him to a different emergency room across the street.
The patient was immediately intubated but soon had two episodes of cardiac arrest, according to the OIG. He was diagnosed with multiple illnesses, including severe sepsis with septic shock, acute respiratory failure, anoxic brain damage, and cardiac arrest. He died about 10 hours after arriving at the ER.
The OIG report confirmed that the patient was later confirmed to be an eligible veteran. He had previously been admitted to the facility in the spring of 2020 and released following treatment for heart failure and a host of other medical problems.
But even if the patient had not been a veteran, the OIG noted that emergency department staff still should have admitted him. Under Veterans Health Administration policy, emergency departments “must never turn away” a patient who arrives by ambulance, the report states. VHA policy also specifies that staff can determine patients’ eligibility “after the initial examination and essential treatment.”
The report criticized facility leaders’ “inadequate response” to the incident, including deciding to issue written warnings to nurses rather than removing them from emergency care, and said it may have compromised patient safety.
During the course of the investigation, OIG staff identified at least four similar incidents in 2018 and 2019 in which patients may have been improperly denied care or had their care improperly delayed at the facility. Staff were required to complete training after the 2019 incidents, but the OIG found continued violations of VHA policy and inappropriate delays of care.
The OIG made several recommendations, including that leaders conduct a further review to determine whether staff involved in the incident should be penalized or referred to the appropriate state licensing boards. The OIG also recommended prioritization of care ahead of patient eligibility and better training for emergency department nurses.
Melanie Thomas, a spokesperson for the North Florida/South Georgia Veterans Health System, told Coffee or Die Magazine in an email that the health system “values the recommendations” of the OIG report.
“We embrace high reliability and are committed to zero harm for our patients,” Thomas wrote. “As outlined in the response, action plans have been completed or are currently under implementation. We remain dedicated to honoring our Nation’s Veterans by ensuring a safe environment and delivering exceptional health care through continuously improving our standards.”