Deficient Care at VA Hospital in Florida Resulted in Wrongful Death: Report

An investigation into a patient’s death at a VA hospital in Florida indicates care in the emergency department was deficient and mismanaged.

The Veteran’s Affairs Office of Inspector General (OIG) released a report (PDF) on June 3, which warns that poor care contributed to a death at Malcom Randall VA Medical Center in Florida. in the spring of 2020.

According to the report, investigators found the patient was treated inadequately by the emergency department (ED) due to staffing levels at the hospital.

The patient was in their 60s and first received care at two other emergency rooms after having laparoscopic colon surgery. The patient then arrived in the emergency department at Malcom Randall 15 days after the last surgery, reporting pain levels at 8 out of 10 in their abdomen. Symptoms of labored breathing, pale complexion, and history of recent abdominal surgery supported assignment of an Emergency Severity Index (ESI) level 2, suggesting a greater risk. Despite the symptoms, the patient was placed into ESI 3, which led them back to the waiting room.

While in the waiting room, the patient started having trouble breathing and eventually even yelled out “I cannot breathe,” leading a nurse to then provided supplemental oxygen, according to the report. The patient soon after 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 that same day.

The OIG received an anonymous complaint stating the patient’s care was mismanaged and resulted in the patient’s death. The OIG report “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 level 2 to the patient.”

Despite the findings, the OIG could not determine if faster care would have saved the life of the patient. The staff also met the proper education, experience, and training standards necessary to work in the ED.

The OIG determined a CT scan taken after the patient’s deterioration, but before death, indicated extensive thrombus in the aorta with blood supply being cut off from multiple organs, according to the report.

The OIG recommended ESI Level 2 patients not be left in the ED waiting room, and determined additional quality reviews are needed due to failures identified in this report.