His wife told the staff she was having difficulty managing him and could no longer care for him at home.

Nevertheless, the emergency room doctor discharged him, saying he did not meet the hospital’s criteria for acute-care admission. When his wife asked about hospice care — which focuses on allowing patients to die with dignity, pain-free — she was told no hospice beds were available.

She took him home but, even with the help of a family member, was unable to get him out of the car. She called 911 and paramedics took him to a local private hospital, where he was admitted.

His doctor there contacted the VA and requested hospice care. The veteran was scheduled for admission to the VA’s hospice unit five days later.

Two days before the scheduled transfer date, he died.

The investigators found that the VA emergency room doctor did not do a complete evaluation of the veteran before discharging him, failing to document the significant decline in his condition the past three weeks. They also found that the VA staff missed numerous opportunities to initiate hospice care.

The investigators were unable to substantiate allegations that the veteran and his wife were treated rudely by the staff or that four hospice beds were available on the day of the veteran’s last visit to the emergency room.

In response to the investigation, the Hampton center has provided training for its entire clinical staff in the VA’s end-of-life care policies.

“The Hampton VA Medical Center takes great pride in its state-of-the-art palliative care facility and dedicated staff,” said Jennifer Askey, a spokeswoman. The facility’s emphasis is on “honoring patient and family choice,” she said.