A Florida Veterans Affairs hospital refused treatment for a veteran dying of heart failure because first responders could not prove his military service, a clear violation of federal law, according to a new report released by a department watchdog Tuesday.

The incident, which occurred at the Malcom Randall VA Medical Center in Gainesville in summer 2020, was not the first failure by emergency medical staff there to provide care to individuals facing critical medical crises. Staff from the VA Inspector General’s Office said without policy and staffing changes, it may not be the last.

“Although facility leaders implemented actions to address concerns identified … since implementation the actions have not been effective in preventing the occurrence of additional patient incidents,” investigators wrote.

“Despite the simulation education and interventions, the OIG learned … that there continue to be delays in the provision of emergency care to patients in the Emergency Department due to inefficient registration processes and practices.”

In a statement to the inspector general, officials at the medical center said the emergency department staff “prioritizes patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.”

But the inspector general found that no individuals have been fired for the 2020 incident, even though prompt action may have saved the veteran’s life.

The veteran — identified only as a 60-year-old man who had been treated at Malcom Randall VA Medical Center for heart issues earlier that spring — was rushed to the hospital by a local ambulance after a neighbor found him unconscious at home.

Emergency responders contacted staff en route to the hospital to inform them that the man was in poor health and was believed to be a VA patient.

But when they arrived, the report states, first responders found the VA staff “belligerent” over the lack of identification and argued for several minutes about whether he was eligible to be treated at the facility.

Under federal law, hospitals with emergency services are “obligated to provide medical screening examinations and stabilizing treatment to patients with emergency medical conditions,” regardless of their eligibility for care in other situations.

After waiting about 10 minutes for staff to admit the man for care, the ambulance staff gave up and drove to another nearby hospital. The patient died of heart failure about 10 hours later.

Inspector General’s Office officials released an initial report last summer that cited multiple failures in the VA hospital staff’s handling of the incident, but did not specifically outline in that report how much time was lost because of concerns about the man’s veterans status.

The new report also details multiple other emergency room failures at the site in recent years, all linked to “nurses’ failure to recognize and accurately assess the patient’s emergency medical condition and nursing competencies.”

Investigators said part of the problem in the 2020 incident may have been grudges held by VA staff against the ambulance crew after a similar incident a year earlier, where medical center nurses were also criticized for failing to put patient care ahead of eligibility questions.

VA staffers told investigators that the first responders created confusion by not communicating the patient’s health status and what personal information they had. But inspector general’s staff, after reviewing case files and radio dispatches, called the ambulance staff “professional” and placed blame for the situation on VA employees.

VA Sunshine Healthcare Network leadership has promised an independent review of the situation to see if staff firings or discipline is warranted. They have also promised other changes — such as better training on the federal law mandating care for individuals in distress — to be completed by the end of September.

The full report is available on the VA Office of Inspector General’s web site.

Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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