An investigation into the staff at Bay Pines VA Healthcare System in Semionole, Florida, determined they left the body of a veteran in a shower room for more than nine hours.
After the body was discovered the staff deliberately tried to cover up the mistake according to the report findings.
The unnamed veteran had passed away back in February of this year while in the hospice unit of the Florida VA.
An investigation was begun and in April, a 24-page report was issued and obtained through a request made under the federal Freedom of Information Act. Investigators had interviewed over 30 witnesses.
According to the Tampa Bay Times, the report stated the incident involved a veteran who died as patient at the Bay Pines facility while in the hospice unit. The hospital “transporter”, a person in charge of moving the bodies of deceased veterans to the morgue, was told by a staff member to move the deceased veteran from the hospice unit to the morgue. Instead of doing what was told, the transporter told the staff member to “follow proper procedure” and contact the dispatchers first. Unfortunately that contact was never made so no one ever showed up to pick up the body.
The body was moved from the hallway in the hospice section of the hospital and rolled into a shower room, where it stayed unaccounted for, for over 9 hours.
Once the mistake and the body were discovered, VA staff “falsely documented” the incident, the report says, and misrepresented why the problem occurred by blaming it on a communications breakdown.
The VA report stated that, “Leaving the body unattended for so long subjected it to an “increased risk of decomposition.”
Other findings of the VA Investigation concluded:
• Hospice staff failed to check a 24-hour nursing report that would signal whether the death was properly reported and failed to ask personnel involved about the handoff.
• Questioned later by investigators, some responsible for oversight at the hospice blamed a shortage of clerical staff — a claim they later recanted.
• Staff failed to update a nursing service organizational chart, hampering efforts to determine who was in charge.
• The hospice unit lacks a structured plan for educating personnel on best practices.
Jason Dangel, the VA hospital’s spokesman, said, “We view this finding as unacceptable.”
Dangel also assured that, “Bay Pines ordered retraining and a change in procedures as a result of the incident, and “appropriate personnel action was taken.”
Dangel did not comment on whether any of the staff were reprimanded or fired.
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