Report Summary

Title: Failure to Provide Emergency Care to a Patient and Leaders’ Inadequate Response to that Failure at the Malcom Randall VA Medical Center in Gainesville, Florida
Report Number: 20-04443-167 Download
Issue Date: 5/31/2022
City/State: Gainesville, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The OIG conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility), after the patient’s death at the University of Florida Health Shands Hospital (Shands).

The inspection team found that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day 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. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.

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 OIG also identified deficiencies in nursing competencies and confirmed that the competency folders for two nurses did not contain the 2019 Ongoing Competency Assessments as required. Although the Emergency Department nurse educator provided newly created, backdated competency assessment documentation for these two nurses, the inspection team did not consider these “replicated” documents to be acceptable forms of verification that the competency assessments were actually completed by the two nurses.

The facility had prior instances of Veterans Health Administration Emergency Medical Treatment and Labor Act (EMTALA)-related policy violations in 2019, resulting in Emergency Department staff being required to complete EMTALA-related training. The actions implemented by facility leaders to address concerns were not effective in preventing the occurrence of additional patient incidents, and delays in the provision of emergency care to patients continued.

The OIG made one recommendation to the Veterans Integrated Service Network Director regarding consideration of administrative action and reporting to state licensing board(s). The OIG made four recommendations to the Facility Director related to the prioritization of emergency patient care and nursing competencies.

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