A Veterans Affairs hospital in Florida refused to provide emergency care to a veteran who was dying of heart failure because hospital staff could not confirm his military service, a report the Department of Veterans Affairs Office of Inspector General (OIG) published on Tuesday revealed.
The incident took place at the Malcom Randall VA Medical Center in Gainesville, Fla., in summer 2020, when first responders transported “an unresponsive patient” to the facility’s Emergency Department.
EMS notified facility staff of the patient’s initials, as well as a contact number for a family member, and “informed facility staff that they did not have any other patient identifying information.”
Upon arrival, facility staff – including four nurses – asked the EMS crew for the patient’s identification information, despite the earlier explanation that they did not have any additional details on the patient. An Administrative Officer eventually joined the nurses and requested more information on the patient in an effort to “verify the patient was an eligible veteran.”
“The EMS responders reiterated they were unable to provide additional identifying information,” the report stated.
After waiting in the ambulance bay “for a period of time … without facility staff attending to the patient,” the EMS crew asked if they should transport the patient to a different facility, to which the VA staff responded “yes.”
EMS reloaded the patient and rushed the patient to another facility where the patient died later that day.
The veteran was identified in the report as a 60-year-old man who had received treatment at the facility earlier that same year.
The Malcom Randall VA Medical Center Director said in a statement that facility staff will 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.”
However, the inspector general’s investigation found that no one was fired for the summer 2020 incident that may have led to the veteran’s untimely death. The OIG team also “learned that similar patient incidents had occurred in 2019, resulting in Emergency Department staff being required to complete EMTALA-related training.”
The OIG recommended that the medical center’s director “ensures that Emergency Department nurse competencies are current, complete, and validated as required, and monitors for ongoing compliance.”
The inspector general also called for the director to conduct “an internal review of the Emergency Department Nurse Educator’s replication of the 2019 Ongoing Competency Assessments and attestation of competency completion to determine whether administrative action is warranted and takes action as appropriate.”