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One elderly veteran with dementia went missing for days from Bay Pines VA Healthcare System after the facility misidentified the patient immediately after calling a Code Orange.

According to an IG report, VA police brought a veteran to the emergency department at Bay Pines VA after finding him asleep on VA property. A few days earlier, the veteran was previously admitted due to intoxication. While hospitalized, the veteran was found “wandering around the hospital.”

A VA psychiatrist evaluated the veteran and determined the veteran had significant cognitive deficits and required continued monitoring and 24/7 supervision due to his impairment.

Later the same day, the patient went missing.

This is where Bay Pines procedures went sideways, which may not surprise many veterans frustrated with the administration of healthcare at that facility.

Code Orange Telephone Game

Clinicians activated a Code Orange. This is a code VA is supposed to call in an emergency when an “at risk” patient goes missing at Bay Pines VA. At risk patients are deemed to be a harm to themselves or others if not located and returned to a safe environment.

Once the Code Orange was called, the facility misidentified the missing patient for two hours due to a look-alike or soundalike name. Policy for missing patients require that they are identified using two identifiers to avoid confusion.

Here is the sequence of events that led to the misidentification:

  1. The missing patient’s nurse notified the unit charge nurse, who in turn notified the flow coordinator that the patient was missing.
  2. The unit clerk allegedly provided the flow coordinator with the wrong patient’s information.
  3. The flow coordinator then contacted the VA police about the wrong veteran.

So, due to the confusion, VA searched for the wrong veteran for two hours, which was likely the key window of time to locate the wandering veteran.

RELATED: VA Settles Excessive Force Lawsuit

No AOD Elderly Veteran Search

Compounding matters, the administrative officer of the day (AOD) failed to follow agency policy requiring the AOD to contact hospitals and shelters to locate the missing patient. The AOD is a person acting on behalf of the Director who serves as the central point of contact. In this instance at Bay Pines VA, the AOD denied knowing of this search requirement.

RELATED: VA Cancels 250,000 Radiology Appointments

Five days later, following an extensive search by VA social workers, the patient was located. He was apparently in the care of a community clinic elsewhere and was returned to VA.

I would be curious to be a fly on that wall listening to Bay Pines VA both explain what happened and also why the veteran would be better off if returned to their facility.

At least the story ended with good news. The elderly veteran did not die while suffering from a bought of dementia. Hopefully, he will now receive the care and support he requires.

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34 Comments

  1. Ben wrote:”I would be curious to be a fly on that wall listening to Bay Pines VA both explain what happened and also why the veteran would be better off if returned to their facility.”

    Yes indeed. I think EVERY veteran that served in the military during the timeframe I did would LOVE to hear them stumble through their version of “extenuating circumstances” for five minutes prior to the patient’s nurse, Charge Nurse, Unit Clerk, Flow Coordinator, and Administrative Officer of the Day being marched outside, stood against a wall, and summarily executed by firing squad for gross dereliction of duty.

    For them to offer up any explanation that amounts to a defense makes a mockery of the word professionalism. Clearly their combined actions were the dictionary definition of chaos. Dare I say that Moe, Larry and Curly more than likely could have done a far superior job for this veteran than these clowns at Bay Pines.

    Ben wrote: “At least the story ended with good news. The elderly veteran did not die while suffering from a bought of dementia. Hopefully, he will now receive the care and support he requires.”

    Based upon this article and other about Bay Pines – – – the ONLY way this veteran will get the care and support he requires is to get to a better VA facility.

  2. (OFF – TOPIC) @ANutterVet – – – This is carry-over from another article. Comments closed before I could reply.

    I do not have your contact info. I already have things in process on my situation. Just thought there might be a few things I could suggest to you regarding yours that I may not have. I do hope you get your situation vis-a-vis your military service straightened out.

    Wishing you the best.

  3. Ben wrote:
    *”Here is the sequence of events that led to the misidentification:

    1.) The missing patient’s nurse notified the unit charge nurse, who in turn notified the flow coordinator that the patient was missing.
    2.) The unit clerk allegedly provided the flow coordinator with the wrong patient’s information.
    3.) The flow coordinator then contacted the VA police about the wrong veteran.

    Doesn’t this remind y’all of a “game” which was played in grade school called “Telephone”! One student says to another student etc. “The sun is shinning!” By the time it gets around the classmates – the phrase is completely changed!
    At least that’s my opinion!

    • P.S.
      Ben also wrote;
      *”Compounding matters, the administrative officer of the day (AOD) failed to follow agency policy requiring the AOD to contact hospitals and shelters to locate the missing patient. The AOD is a person acting on behalf of the Director who serves as the central point of contact. In this instance at Bay Pines VA, the AOD denied knowing of this search requirement.”*

      The last sentence is very important. Did the AOD knowingly NOT know about the search requirement? Or, was the AOD just giving a “CYA statement”?
      Since the AOD is a VA employee, you’ll never learn the truth!

    • @Elf – – – Sure does, now that you mention it. Here’s how they play it at Bay Pine VA:

      Nurse: Poor Jim Clement, wee bit of dementia today. We’ll have to be especially watchful of him.
      Charge Nurse: No problem.
      Clerk: Logged in system.

      The SUN IS SHINING . . .

      An hour passes during which our dementiaed hero wanders off to explore strange new worlds, to seek out new life and new civilizations, to boldly go where no man has gone before . . .

      Nurse: Oh my God! My patient is missing!
      Charge Nurse: We need to activate AGENT – – er, I mean – – CODE ORANGE.
      Clerk: I will give the information on Jim Clement to the Flow Coordinator.
      Flow Coordinator: Thank You. I understand we are CODE ORANGE looking for Crazy Elf.

      LIGHTNING HAS STRUCK !

      Yep, same game. Just ‘modernized’ a wee bit . . .

      • Jim Clement…your awesome! That was a great and funny ass hell moch up of the story….you had me laughing. I’m a Navy Vet and go to the Portland VA in Oregon. They have been professional , attentive, knowledgeable, and even caring in ALL my heath care. Maybe I’m one of the fortunate one’s or based on conversing with other Vets the Portland VA is actually a good VA.

      • @M. Temple – – – I’m a 18+ year Navy Department Veteran too. First served as a U.S. Marine, then finished my time as an Operations Specialist (OS) (NEC: 0332, 0334) on LCC, DD’s, CG’s plus one shore tour at a Fleet Command Center. Med boarded out on my retirement-eligible enlistment in ’93. Fighting for my bennies ever since.

        Don’t recall seeing you comment before, but I could have missed. Not as sharp as I used to be.

        Welcome Aboard!

      • Lol. Yep about it. Lightening. “Telephone” game, phone tag, passing the accountability buck around, calls to numerous insulating secretaries/staff, unions, special connections of staff inquiries, to VA attorneys to Public Relations, to possible gas-lighting of patient, or AstroTurfing issues, the covering of all their asses… no “truth” to be found or heard. How can this be kept out of public consumption and handled internally only. Time to retaliate against the news leakers. Need to tighten up on leaks. VA protection status up to Defcon 1. Loose lips sink ships… aka USS VA Titanic. Lessons learned about how to cover things up better for next time. Send him off to the Disruptive Committee and Red Flag his file as a Domestic Terrorist as training could label him a ‘danger to others.’ Censor censor. Thank you for your service!

        Perhaps some Cliff’s Notes should be written or tattooed on patient’s forehead like they have gone to doing on surgery patients (with many reasons/reports why) with the markings/notes of/on limbs or surgeries to ensure the wrong limb is not amputated or wrong nut removed, or both. Or gall bladder removed instead of appendix, etc. Not kidding.

        How can staff call patients with the wrong test results or others test results? Call to inform vet he is dying and will experience, or should be experiencing, major organ failures and on deaths door step, should be in the hospital now and not home drinking against MD orders. Ahem. Feeling fine, haven’t drank in years, “are you calling the correct patient?” Oh yes it’s you the file is in front me now with all the reports and email requests to contact you. Your blood alcohol level was off the charts. Blah blah. ‘I am fine, not drinking, not going to the hospital, clinic visit coming up shortly, thank you.’ Few days later at the CBOC. No calls like that were made to you and we know nothing about it blah blah. Total ignorance, incompetence, cover-ups, can’t read but got nursing degrees, high tech “Telephone” games with the info in their faces?

        An OT from the supply shortage topic after thoughts. One small short example. How are things dangerous or why prescriptions are needed for simple health supplies like CPAP masks. VA is out of a certain kind. Fine, will get one from a local med supply store, been waiting weeks now. Wrong. “You need to stick to your VA and go back to them.” “A prescription is required for CPAP masks” which the VA PCP or specialty clinic would not provide. The wrongs, greed, non-sense, insanity, goes beyond the VA. Thanks AMA/Big Bro/Sis and predatory profiteers.

        Trudging around in a “strange new world.” Doing that for sure now. The Borg is winning.

      • @T – – – Agree with your points/questions. One would think that a replacement CPAP mask could be had at the local Wally World without a prescription, wouldn’t one?

        On another note, going to pick up my beloved ashes today, then continue going through all of her paperwork. Will be attending Church this coming Sunday with a friend who will take me grocery shopping after – – – then spend a few hours with me after looking over some financial documents in order to try to explain them to me. I will be taking good notes. Going to be scheduling that appointment with the probate attorney soon.

        Hard day ahead.

        As you know, my wife was the Chief Financial Officer. If I am not sleeping in the rain, my dogs are healthy, and I eat once daily – – – I am a pretty content guy.

        Hope this finds you well.

    • Game, Well done.
      She said , he said “someplace where the sun don’t shine” is one version.

      But not is Berkely anymore. It’s now known as “They Said”

  4. Y’all have to read this article from “Politico” on 04/04/2019!
    It’s kinda long. Yet, very informative.
    *”https://www.politico.com/magazine/story/2019/04/04/donald-trump-veterans-affairs-jeff-miller-226483″*

    • I actually receive lots of stuff on VA by googling
      *”veterans administration scandals of 2019″*
      You’ll read and view videos on this subject.
      Have fun!

  5. (OFF TOPIC) – – – Wan to know how sick this country really is?

    “https://www.msn.com/en-us/news/politics/a-democratic-candidate-claimed-she-removed-77-bullets-from-pulse-shooting-victims-it-was-all-a-lie/ar-AAEGVh2?li=BBnb7Kz”

    She only faces a $3000 fine? Why isn’t she in jail???

    • Google “David Briscoe” who claimed to have been a substitute teacher at Santa Fe high school in TX where they had a mass shooting that he said he had witnessed and aided victims during the attack. CNN and others lauded him as a hero, BUT turns out he never even worked there. What kind of scum capitalizes off of a mass shooting as a source of personal fame and unearned heroism. I say JAILTIME not a measly fine. I’m not sure if he even had any consequences when he was finally found out to be a liar.

    • Jim,
      What would one want from a “wannabe politician”! She’s just like a majority of our political boobs are today. Pure unadulterated LIARS!

  6. Veterans are here is well and don’t have to used Veterans Medical Center where i lived is terrible so Veterans if know good one telled me even Mission Act don’t either…Semper Fi Don’t Surrender.

    • Good to hear all well there, Arnold. Semper Fi my young brother! San Antonio has pretty good facilities so far.

      • The new small vha clinic in Deltona FL is a waste of taxpayers monies.
        These so-called healthcare professionals can’t even read their own lab reports. Let alone diagnose illnesses. In the past 90 days (2 lab reports), these alleged providers didn’t see where I had another UTI (urinary track infection)! Because my prostate has enlarged three (3) times its size. Which doesn’t allow my bladder to completely emty!
        I’m currently seeing outside doctor to correct this problem.

        They, Deltona fl. VHA clinic, even refuses to make copies of your “progress notes”. Saying they “…don’t have to give them to you!”
        Which is a violation of federal law!

        There’s MORE. Only I think I’ve given a sad picture of how this clinic operates!

      • @Elf – – – Need to file a complaint? See if any if this helps. For future reference.

        NPI Number
        1922331982
        Enumeration date
        Sep 09, 2009
        LBN Legal business name
        ORLANDO VAMC
        DBA Doing business as
        DELTONA VA CLINIC
        Authorized official
        ERIN POTTER – (NPI TEAM MEMBER)

        Info current as of July 2018.

      • Jim,
        Thanks brother. Already filed one hell of a complaint against those reprobates.
        They’re feeling the pain NOW!

      • Good! High about time they did. While none of us will ever receive true justice (THAT would have been the VA giving us what we had earned in a timely manner according to the law without obfuscation) every time any of us makes these reprobates feel some pain for the anguish and pain they have caused us over the years due their negligence, greed, and callousness – – – I rejoice a little bit inside. Helps to give me a bit of hope that someday, just maybe my situation may get straightened out too.

  7. The President can expand access to non-VA (real health-care) 1000%, but if Grandfathered Choice 40 dis qualifies most veterans it will still seem usage is down. That’s why it was retained in the new and improved VA Mission Act. Getting an appointment is easy. I got one on a saturday once that only took ten min.’s.
    -This is for another article, but its comments were closed.- Had to say something…

    • Yes it was. You are referring to Jim Turner who ended his pain and life this past holiday season.

      “https://www.tampabay.com/news/military/jim-turner-a-retired-marine-colonel-took-his-life-at-the-bay-pines-va-campus-he-was-the-5th-veteran-to-do-so-since-2013-20181217/”

  8. He was running from: “5G” Smartphones, in an effort to save his Fourth Amendment rights to PRIVACY!

    Odds are, the local Universities were trying to get him to become one of the newest, hazed recruits.

    “Your my boy blue!”

    I say let him go, and FREEDOM ON. Let him come in the next time he feels like: “Treatment!”

  9. Check this out, if your a “blue water navy member”!
    *”https://www.military.com/daily-news/2019/07/22/group-sues-over-delay-processing-benefit-claims-blue-water-navy-vets.html”*
    If you are, maybe your name could be added.

  10. oig report va fortwayne causing veterans to become opiod dependant

    sent in for publication

    VA Socialized Medicine At Its Best
     
    Nothing but negative news coming out from VA cops falsifying records, assaults, killing vets to supervisors that are convicted murders. Socialized medicine at its best hiring right out of the penitentiary. Veterans are told to seek mental health, VA approves it than refuses all the bills. Veterans in crisis become more stressed out wont seek mental health anymore and end there lives. VA Fortwayne destroying lives and fueling the opioid epidemic. Every Dr that failed to follow the required standards for opiods and the chief of staff at the Fortwayne VA need removed. The government that says they care are the ones causing this epidemic. 300,000 veterans deaths from a incompetent agency. This agency buries it mistakes as there no accountability as lives are ruined. We have invaded other countries for much less when are we going to invade the VA? This government has failed to hold any one accountable but go after whistle blowers, veterans and the disabled.

  11. This is occurring right now;
    *”https://youtu.be/_2BNdZeKWYM”*
    It’s the senate hearing on VA’s whistleblowers accountability!

  12. Off Topic – Cannabis As Your Medicine? –

    FIRST, let me say . . . US, STATE GOVT’S, and ALL YOUR AGENCY’S, PLUS the VETERANS ADMINISTRATION . . .

    FUCK YOUR CANNALAWS, POLICIES, and RESTRICTIONS, THEY ARE ALL CRIMES AGAINST HUMANITY.

    If we keep referring to Cannabis as medicine, then don’t complain when the Gov’t, FDA & DEA want their hands on Cannabis.

    Research clearly shows that Cannabis is safer than Alcohol, but Cannabis has more restrictions & regulations on its cultivation, use, and consumptuon.

    If we keep referring to being medicated by Cannabis, then you’re just giving those hard headed Agency Leaders and Legislators, the right to jump on the wagon of Cannabis regulation, control, taxes & limitations.

    Cannabis to me is like basil. Basil added to my tomatoe soup. A soup where I’ll dip my grilled cheese sour dough, or Jewish rye bread sandwich into my flavorful & healthy Canna Infused Soup.

    The wording that is attached to Cannabis mean things. And in law, the wordings attached to Cannabis means everything.

    Before you judge what I just wrote, give it more thought before coming back at me in a negative way.

    Pre-Prohibition was precedent “stare decisis” before all the propaganda, and Anslinger’s influence on the Congress. Which then led Prez FD Roosevelt to sign the 1937 Marijuana (Marihuana) Act = the start of Cannabis Prohibition.

    Referring to Cannabis as your medicine invites, and gives the Gov’t and it’s Agency’s the go ahead to control Canbabis. And that is exactly what they want.

    My belief is this; “Alcohol-Lovers freely brew their favorite fluids, so I want to freely cultivate & consume my favorite plant (Cannabis), and without prosecution.”

    That’s why most States will toss us a few slices of bread, and because of ignorance, most willl accept it as a full loaf of bread.

  13. Another short quickie/question: Don’t they have something called “Silver Alerts” for missing seniors or those known to have dementia or other issues that may lead to death or serious injury? Five days? Seems they spent more time bouncing info all over the place, covering their butts, instead of actions. The VA can network with civilians to attack and play retaliation games with vets who don’t bow to their fascist evil ways, why not something like that for patient care? Since we can’t depend or trust those professionals in modern health care workers/activist/haters/the mass incompetence they can always resort to the many kinds of alarms/alert systems and such on patients they all need to keep careful watch over. Or put them in lock down units like some nursing homes have done or do.

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