Report Summary

Title: Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida
Report Number: 20-03535-146 Download
Issue Date: 6/3/2021
City/State: Gainesville, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The OIG assessed allegations that a patient’s care was delayed and mismanaged in the facility’s Emergency Department resulting in the patient’s death, and facility leaders ignored complaints of inadequate Emergency Department nurse staffing levels. Initially, the OIG had concerns regarding the impact of the pandemic on the scheduling and quality of the patient’s hemicolectomy surgery completed 15 days prior to the patient’s death; however, no deficiencies were identified.

Between postoperative days 10 and 15, facility surgical staff instructed the patient several times, via phone, to seek urgent medical attention to address not eating, abdominal distension, and vomiting. The patient presented to non-VA hospitals twice and to the facility’s Emergency Department on the third occasion, where the patient was triaged as an Emergency Severity Index (ESI) 3, evaluated by a nurse practitioner, and returned to the waiting room. A short time later, the patient, yelled “I cannot breathe,” fell out of a chair, became unresponsive, and died later that day.

The OIG substantiated that the patient’s Emergency Department care was deficient and mismanaged, which may have resulted in a delay in care. The OIG found the clinicians who triaged the patient failed to consider all reasonable causes of the patient’s shortness of breath, communicate with the patient’s surgeon, and assign an ESI 2.

The facility did not have a policy that prohibited ESI 2 patients from remaining in the waiting room, which conflicted with guidance from the Emergency Nurses Association.

The OIG did not substantiate inadequate levels of nursing staff in the Emergency Department during the week of the patient’s death or that facility leaders received complaints.

The OIG made two recommendations to the Facility Director related to ESI 2 patients not remaining in the waiting room and review of identified concerns related to the patient’s pre-code Emergency Department care.