Alleged Inadequate Response to a Missing Patient and Safety Concerns at the Bay Pines VA Healthcare System, Florida

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations of an inadequate response to a Code Orange and patient safety concerns for a missing patient at the facility. The OIG substantiated that the patient went missing from the facility in spring 2018. Staff contacted the covering physician, who determined that the patient was at risk; however, the physician did not document the assessment until after receiving a call from a facility leader. Staff did not comply with the facility policy for patient identification and the facility lacked a policy addressing look-alike or soundalike names. As a result, staff misidentified the wrong patient as missing and approximately two hours elapsed before staff corrected the error. Although the administrative officer of the day did not comply with policy to contact outside hospitals and shelters, unit staff and social workers made multiple calls and located the patient at a community hospital five days after being missing. The facility submitted issue briefs, conducted a Code Orange debrief, and later completed a root cause analysis. The facility’s incident report did not address the misidentified patient, and the fact finding did not review all personnel involved in the event. Prior to the event, staff received training on managing missing and wandering patients and the facility distributed a Code Orange visual aid for reference. In response to the event, VA police began conducting annual drills, and the unit nurse managers held a staff meeting and daily huddles to reinforce the importance of following the Code Orange protocols. In addition, the nurse managers introduced time-out huddles prior to calling a Code Orange to ensure the correct identity of the missing patient. The OIG made three recommendations related to patient identification, documentation, and understanding duties and responsibilities.