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The emergency department was so overcrowded, patients were left on stretchers in hallways, some for as long as 14 hours and others who left without ever being seen.

A year later, they found delays in processing “urgent laboratory tests” and that patients had died in the emergency room.

OSHA, which monitors workplace safety, issued multiple citations to the hospital in May 2016 for improper disposal of human tissue.“It’s a house of horrors,” said Sean Higgins, a former logistics technician at the hospital.

Then there was the botched surgery in September 2016.

They may represent a small sliver of the VA’s 168 hospitals across the country, but the stakes are high for the thousands of veterans reliant on them.

Mary Davis says she knows first-hand just how bad care can be at the Memphis VA —and how tragic the consequences. Davis, collapsed on the kitchen floor in their Atoka, Tenn., home in 2015, an MRI scan showed he had a tumor in his neck.

The hospital is one of only four on which the VA's top health official, acting Under Secretary for Health Poonam Alaigh, requested weekly briefings, according to the documents.

The Memphis VA scores only one out of five stars in the agency’s quality-of-care rankings and the documents show reports of threats to patient safety at the hospital soared to more than 1,000 last year, up from 700 the year before.

By the time they caught it, the tumor had damaged his spine and he is now paralyzed.“They should have caught it,” she told USA TODAY.

What they didn’t realize is that they had not removed plastic packaging on the catheter before inserting it. An investigation found that after the procedure he had lost complete blood flow through the artery. Cashour, the VA press secretary, said the agency is continuing to investigate problems discovered in the top-to-bottom review conducted in recent months, including shortfalls in the surgical department.

He said the VA wants to “understand how these problems developed, and hold accountable those responsible.”Rep.

Among the other serious incidents investigated in 2016: The medical center mishandled a tissue sample resulting in a repeat biopsy, a provider perforated a patient’s colon during a colonoscopy, and a patient with abdominal pain and blood in his urine waited two hours in the emergency room before leaving for another local hospital where the patient “was deemed urgent and seen immediately.”According to VA statistics, the hospital is among the worst in the country for patient safety and inpatient outcomes.

Death rates following acute care or pneumonia treatment also are among the worst of any of the agency’s medical centers.

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When they cut into his leg, they found a 3-inch segment, and after the procedure, they found another 7 inches in the amputated limb.

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