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An unidentified veteran died at the Bay Pines Veterans Administration facility in February. The staff of the its hospice unit, located outside of St. Petersburg, Florida, reportedly ignored the body for over nine hours.
Through a Freedom of Information Act request, the Tampa Bay Times obtained the report from the hospital's Administrative Investigation Board, revealing just what went wrong before and after the veteran's death..
The incident was described in the report, according to the Tampa Bay Times:
Once the veteran died, hospice staff members made direct verbal requests to an individual described as the transporter for the body to be moved to the morgue. The transporter told them to follow proper procedures instead by contacting dispatchers. That request was never made, so those responsible for taking away the body never showed up.
At first, the body was moved to a hallway in the hospice, then to a shower room, where it stayed, unattended, for more than nine hours.
The report also said that hospice staff members "demonstrated a lack of concern, attention and respect” for the veteran.
- 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 lacked a structured plan for educating personnel on best practices.
Independent Journal Review spoke with an embalmer who wishes to remain anonymous.
She described the problem with the body being left unattended:
“From the moment someone passes away the decomposition process begins. Outside factors also play a role in speeding up decomposition. I would assume a shower room would be hot and humid and cause the body to start decomposing much quicker.”
She also said that most hospitals have refrigeration as a “very common” practice to preserve the body until it can be embalmed.
Hospital spokesman Jason Dangel told the Tampa Bay Times that the hospital was retraining staff members and changing its procedures.
Dangel wouldn't comment on whether or not anyone had been fired but told the Times:
“We feel that we have taken strong, appropriate and expeditious steps to strengthen and improve our existing systems and processes within the unit. It is our expectation that each veteran is transported to their final resting place in the timely, respectful and honorable manner. America’s heroes deserve nothing less.”
Florida Representative Gus Bilirakis addressed the incident on his Facebook on Friday. He claimed that not one VA employee had been fired:
“I am deeply disturbed by the incident that occurred at the Bay Pines VA hospital, and even more distressed to learn that staff attempted to cover it up. The report details a total failure on the part of the Department of Veterans’ Affairs and an urgent need for greater accountability. Unsurprisingly, not a single VA employee has been fired following this incident, despite a clear lack of concern and respect for the Veteran. The men and women who sacrificed on behalf of our nation deserve better.”
Veterans suffering at the hands of staffing problems seems to be becoming increasingly more common.
A veteran in Oklahoma was recently discovered dead with maggots in his wound due to a lack of an ability to change his bandages. A medical director was required to supervise a morphine pump during the bandage changes, and the facility had not been able to hire one for over two months.
This is the third VA facility to be called into question this month.