IG: Gainesville VA death involved ‘deficient’ care

U.S. Department of Veterans Affairs sign
U.S. Department of Veterans Affairs sign
Jonathan Weiss via Shutterstock

The Department of Veterans Affairs inspector general says a patient who died last summer at Gainesville’s Malcom Randall VA Medical Center received “deficient and mismanaged” care.

The findings are part of a report issued last week from the VA’s Office of the Inspector General (OIG), which received an anonymous complaint alleging that delayed and mismanaged care led to a patient’s death. The report confirmed some of those allegations, although it did not determine they were responsible for the outcome. 

“The OIG found the nurse and nurse practitioner failed to consider all reasonable causes of the patient’s shortness of breath, communicate with the patient’s surgeon, and assign an ESI [Emergency Severity Index] level 2 to the patient,” the report said. “Even with these failures, the OIG was unable to determine if more expeditious care would have affected the patient’s mortality.”

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The report said the patient, a smoker over age 60, had a history of medical issues and had undergone surgery 15 days prior to death. The patient came to the facility with serious abdominal pain and having troubling breathing. 

The report said the patient should have been designated an ESI level 2 and received immediate care, rather than a level 3 designation and returned to the waiting room, where the person later yelled “I cannot breathe” and fell forward out of a wheelchair.

However, Malcom Randall staff told investigators that a level 2 designation would not have changed the hospital’s response. 

“The nurse and nurse practitioner informed the OIG that had the patient been assigned an ESI level 2, the patient would still have been sent to the waiting room as no beds were available in the Emergency Department,” the report said. 

The report made two recommendations: 

  • The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.

  • The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.

A spokesperson for Malcom Randall said both of the recommendations were completed as of May 28, which was six days before the release of the report. 

In 2019, the VA gave its Malcom Randall facility a three-star rating out of five for overall performance relative to other VA facilities. The VA has since discontinued the rating system

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