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(AP) - Several factors including staffing shortages and a lack of communication may have contributed to a higher-than-expected mortality rate among critically ill patients at a Kentucky veterans hospital.

The consulting firm that reviewed the Veterans Affairs Medical Center on Cooper Drive in Lexington found instances of emergency triage performed by a desk clerk; nurses not being able to readily identify or contact on-call residents; and doctors' orders not being followed, the Lexington Herald-Leader reported.

The high mortality rate among patients treated in the hospital's intensive care unit prompted local and regional VA officials to call in the McLean, Va.,-based Booz Allen Hamilton consulting firm to investigate, the newspaper reported.

In early September, the firm issued a scathing report about conditions throughout the hospital.

Its report found insufficient nurse staffing levels along with other staffing shortages among doctors, residents and interns. It also noted nursing education and certification levels that were below national standards.

And the firm found that the hospital had difficulty admitting patients because of a "daily house-wide gridlock," which sometimes resulted in patients being transferred to other hospitals until the VA hospital could take them back.

"The higher-than-expected ICU mortality rate at Lexington VA is likely the result of multiple factors, which, in concert, have a negative impact on the quality of care in multiple hospital units," the report said.

From Jan. 1 to July 23, 58 of 494 patients who had been treated in the VA hospital's intensive care unit died, according to the report. According to the consulting firm, the intensive care unit mortality figures included people who died within 30 days of completing their stay in that unit.

The report found that the mortality rate among patients transferred to the ICU within 48 hours of being admitted to the hospital was 18 percent - four times higher than the death rate among those admitted directly to intensive care.

A safety climate survey done by the consultants indicated that two of three intensive care unit staffers would not feel safe being treated as a patient. High percentages of staffers in other departments gave the same response.

Since the report was issued, a former nurse at the VA hospital, Maria Kelly Whitt, has been accused of killing a 90-year-old patient with an overdose of morphine.

Whitt, 32, of Mount Sterling is accused of giving Jesse Lee Chain lethal doses of morphine on Sept. 3, 2006. She has pleaded not guilty to a murder charge.

Two days after Whitt's arrest, a special agent in the U.S. Department of Veterans Affairs' Office of Inspector General testified at Whitt's detention hearing in federal court that at least two more patients died under suspicious circumstances while under her care.

Two-and-a-half weeks after the report came out, a 42-year-old VA hospital registered nurse was found dead in a restroom on the hospital's sixth floor, which houses the intensive care unit. The Fayette County coroner's office is awaiting toxicology test results.

Shortly after the consulting firm's report was issued there was a major shakeup among top managers at the VA Medical Center, and the hospital began working with the consultants to make changes. In an e-mail to the Herald-Leader last week, the hospital's public affairs office said officials are working to increase staffing and assign fewer patients per nurse, among other changes.

(Copyright 2009 by The Associated Press. All Rights Reserved.)