Report blasts Malcom Randall VA hospital's delay in emergency care of veteran who died

The safety of patients taken to the emergency department at Malcom Randall Veterans Affairs Medical Center in Gainesville has been called into question by federal investigators who say delays in a patient's care two years ago preceded his death.

The U.S. Department of Veterans Affairs Office of Inspector General said in its investigation released Tuesday that nurses and other hospital staff failed to provide care to an unidentified veteran in the summer of 2020 after an ambulance crew brought him to the emergency department in a coma.

The report said staff at the hospital allowed the man to go untreated as they tried to determine if he was a veteran. The ambulance took him to UF Health Shands, where he did receive care but later died.

The report also criticized the VA center leaders’ “inadequate response” to the incident. That included disregarding recommendations to remove some nurses from emergency care and instead issue written warnings.

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"The (Office of Inspector General) determined that the Facility Director’s decision to rescind the recommended discipline of the involved facility staff, while not a violation of policy, potentially compromised patient safety in the Emergency Department," the report states.

Despite continued training for hospital staff, the report goes on to state, "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."

In an emailed statement, the VA hospital's acting public affairs officer Melanie L. Thomas said the North Florida/South Georgia Veterans Health System "values the recommendations of the Inspector General."

"We embrace high reliability and are committed to zero harm for our patients," she said in the email. "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."

Emergency Department staff 'wasted critical time'

In describing the incident in 2020 when the patient died, "The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance."

It adds that EMS personnel, while en route to the hospital, explained the “criticality of the patient’s condition and the limited patient identifying information available.”

The EMS personnel told the emergency department their patient was unresponsive patient with a Glasgow Coma Scale score of 8. “A GCS score of 8 or less indicates a severe impairment of consciousness and almost always requires emergency intubation, the report said.

It points out that 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 says. “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 report adds that the EMS responders reiterated they were unable to provide additional identifying information.

“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,’” the report said.

The report says that Emergency Department staff  “wasted critical time by continuing to concentrate efforts on patient identification versus patient care.”

After being transported to Shands, the patient died 10 hours later, the report says.

The report adds that an Administrative Investigation Board determined the event was a violation of the VA's Emergency Medical Treatment and Labor Act policy, and the board “substantiated an inappropriate delay of care.”

“At the time of this incident, facility protocols included Emergency Department nursing staff meeting EMS in the ambulance bay, screening the patient for COVID-19, and transporting the patient into the Emergency Department to limit exposure to COVID-19, the report said. “Prior to the COVID-19 pandemic, patients transported to the Emergency Department by ambulance were brought directly into the Emergency Department by EMS responders and a charge nurse would direct them to a room for triage.”

Similar poor treatment of other patients

The OIG investigation found that similar patient incidents had occurred in 2019, resulting in Emergency Department staff being required to complete training.

“During the course of the inspection, the OIG team identified additional concerns related to the Emergency Department nurses’ failure to recognize and accurately assess the patient’s emergency medical condition, and nursing competencies,” the report says.

This article originally appeared on The Gainesville Sun: Delays at Gainesville VA hospital preceded veteran's death, feds find