Investigation of Patient Death Finds Deficient Care at VA Hospital

by Jennifer Henderson: For Entire Post, Click Here…

Emergency department triage may have resulted in delay in care.

The emergency department triage of a patient who later died at a Florida VA facility was “deficient and mismanaged,” according to a new report issued by the VA Office of Inspector General.

The patient presented to the ED at Malcom Randall VA Medical Center in Gainesville last summer, 15 days after having laparoscopic colon surgery at the same facility.

The patient — who was in their 60s and had also sought care at two other EDs in the days following their surgery — arrived at Malcom Randall with constant abdominal pain of 8 out of 10, labored breathing, and pale complexion in addition to having had the recent abdominal procedure, according to the OIG report. However, the patient was assigned an emergency severity index (ESI) level 3 (meaning they could wait to be seen) by a nurse, evaluated by a nurse practitioner, and returned to the waiting room.

During the next hour, the patient yelled, “I cannot breathe,” and the nurse provided supplemental oxygen, according to the report. Soon after, the patient fell forward out of a chair, and a code blue was initiated. At that time, the patient was taken to an exam room and was noted to be unresponsive with agonal breathing. The patient was then admitted to the surgical intensive care unit and died later the same day.

The OIG said in its report that, after the incident, it received an anonymous complaint, alleging the patient’s care was mismanaged and resulted in the patient’s death. The complaint further alleged that facility leaders ignored allegations of inadequate staffing levels in the ED.

As a result, the OIG initiated an inspection, and ultimately determined that the nurse’s documentation about the patient supported the need to have triaged the patient as one who could not have waited to be seen.

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