First they moved the dead body into a hallway. Then they took it into a shower room.
There it remained, ignored, for more than nine hours. No one showed up to take it to the morgue because no one called the dispatchers.
Not much is known about the unidentified veteran who died in hospice care at the Bay Pines VA Healthcare System outside St. Petersburg, Fla. But a hospital investigation made public Friday by the Tampa Bay Times criticizes staff members for leaving the veteran’s body unattended for such a long time and then trying to cover up their mistake.
The veteran died in February, and the Times obtained the report from the hospital’s Administrative Investigation Board through a Freedom of Information Act request. Investigators interviewed more than 30 witnesses, the Times reported, finding that hospice staff members “demonstrated a lack of concern, attention and respect” for the veteran and subjected the veteran’s body to “increased risk of decomposition.”
According to the heavily redacted report, the veteran died while receiving treatment in the hospice unit at the sprawling medical complex on Florida’s Gulf Coast. When staff members learned the veteran had died, the report says, they asked a transporter to carry the body to a morgue. The transporter allegedly told them to contact dispatchers instead.
“That request was never made, so those responsible for taking away the body never showed up,” the Times reported.
The body sat in a hallway for an unspecified amount of time before staff members moved it into a shower room, according to the Times. They left it there unattended for more than nine hours, investigators reportedly found.
Decomposition of the human body begins within minutes of death. The process, called autolysis, or self-digestion, begins when cells lose oxygen and tissues start to break down.
When the veteran’s body was finally moved, Bay Pines staff members “falsely documented” the incident and tried to blame their mistakes on a communication breakdown that never happened, according to the Times. Staff members also tried to pin blame on a lack of clerical staff in the hospital, and they failed to update an organizational chart to make it harder to determine who was in charge, investigators found.
A Bay Pines spokesman called the report’s findings “unacceptable” and told the Times that the hospital was retraining staff members and changing its procedures in response.
“We feel that we have taken strong, appropriate and expeditious steps to strengthen and improve our existing systems and processes within the unit,” hospital spokesman Jason Dangel told the Times, declining to say whether any workers had been fired. “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.”
Rep. Gus Bilirakis (R-Fla.) criticized the Department of Veterans Affairs for the way the hospital handled the veteran’s death.
“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,” Bilirakis said in a Facebook post Friday. “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.”
At least two other veterans care facilities have come under fire this month amid claims that they failed to properly care for patients. In Oklahoma, a physician assistant and three nurses resigned from a state veterans affairs facility after a veteran who had a wound infested with maggots died in October, the Tulsa World reported. In Wisconsin, a dentist resigned from a state veterans affairs hospital after being accused of treating hundreds of patients with equipment that had not been properly cleaned, according to the Associated Press.
More from Morning Mix