A patient who died in the emergency room at the Malcom Randall Veterans Affairs Medical Center in Gainesville, Fla., was incorrectly triaged, according to a June 3 report from the VA Office of Inspector General.
The patient, who received laparoscopic colon surgery at the facility in summer 2020, sought care at the emergency department 15 days after the procedure. Between day 10 and day 15 post-surgery, the patient had several conversations with the facility's call center regarding abdominal distension and vomiting. On three occasions, the call center instructed the patient to seek emergency care, according to the report. The patient went to non-VA hospitals the first two times, returning to Malcom Randall Veterans Affairs Medical Center on the third occasion.
Upon arrival, a nurse and nurse practitioner triaged the patient as level three and returned the patient to the waiting room.
"Just over an hour after the patient arrived at the facility's emergency department, the patient fell forward and was noted to be unresponsive and cyanotic with agonal breathing," the report said. The patient was then admitted to intensive care and died later that day.
The patient should have been triaged as level two, meaning they could not wait to be seen, the report said.
"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 [emergency severity index] level 2 to the patient," the report said.
The OIG could not determine whether "more expeditious care would have affected the patient's mortality."
The OIG issued two recommendations to the facility director: ESI level two patients should not remain in the waiting room, and evaluations of additional quality reviews are needed based on the failures identified in the report.
A spokesperson for the medical center told local CBS 4 News the OIG's recommendations were implemented as of May 28.
"Any death that happens is tragic, and certainly we all feel for the patient and for the family," Thomas Wisnieski, facility director, said during a virtual town hall meeting June 4, according to The Gainesville Sun, adding that the nurses involved have since struggled with feelings of guilt.
"We're not perfect by any means, but one of the things that happens within our system is that if there's something that goes wrong, we own it, and we look to fix it," Mr. Wisnieski said.
Editor's note: Becker's has reached out to Malcom Randall VAMC and will update the report as more information becomes available.