Malcom Randall VA Medical Center in Gainesville, Fla., failed to provide emergency care to an unresponsive heart failure patient because hospital staff could not verify his status as a veteran, according to a May 31 report from the Department of Veterans Affairs' Office of Inspector General.
Despite paramedics calling ahead to notify the VA hospital of the patient's critical condition and limited identifying information, emergency department nurses and an administrative officer at the VA hospital "wasted critical time concentrating efforts on patient identification (i.e., determining whether or not the patient was a veteran, which he was) rather than on patient care," the Inspector General said.
The patient was transported to the University of Florida Health Shands Hospital in Gainesville, where he died 10 hours later.
An administrative investigation board reviewed the incident, which occured in the summer of 2020, and determined that it violated the VA's Emergency Medical Treatment and Labor Act policy.
"The emergency department nurses disregarded EMS personnel's patient status report, failed to recognize the patient's emergency medical condition and inaccurately assessed the patient's condition," the report said.
The VA hospital also has a history of EMTALA-related violations and was required to train emergency department staff on the law in 2019, according to the report. Despite this additional training, the Inspector General's most recent investigation found "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 Inspector General issued four recommendations to the hospital to remedy this issue.
"We embrace high reliability and are committed to zero harm for our patients," Melanie Thomas, acting public affairs officer for the VA hospital, told The Gainesville Sun. "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 healthcare through continuously improving our standards."