GAINESVILLE, Fla. – 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 Hospital, where he did receive care but later died.
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 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.
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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.
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.”
The OIG investigation found that similar patient incidents had occurred in 2019, resulting in Emergency Department staff being required to complete training.