(WASHINGTON) -- Sterile supplies kept in dirty facilities, crucial equipment left out of stock, $15 million worth of untracked materials and insufficient leadership in place to enact changes -- this perilous picture of inadequate medical care prompted the Department of Veterans Affairs’ internal watchdog to release a rare preliminary report Wednesday on a medical center serving more than 98,000 veterans in the nation’s capital.
The VA Office of the Inspector General found that conditions at the Washington, D.C., VA Medical Center have repeatedly put patients “at unnecessary risk” and are jeopardizing “a significant amount of assets of the Federal government,” according to the preliminary report.
While the OIG is continuing to survey conditions at the center, it released a preliminary report “given the exigent nature of the issues ... identified and the lack of confidence in VHA [Veterans Health Administration] adequately and timely fixing the root causes of these issues.”
The OIG has not yet identified any patients directly harmed by the conditions, but the inspection so far has identified several issues detailed in the report, including:
• Supply shortages of important medical devices, including one March 15 case in which the center ran out of bloodlines for dialysis patients. The staff had to borrow bloodlines from a private hospital before administering dialysis.
• Inadequate inventory management, leading to insufficient patient care. In June 2016, the report states, a surgeon used expired surgical equipment on a patient. In another case, prolonged use of expired sterilization tools meant nearly 400 items could have been incorrectly deemed sterile.
• Dirty storage facilities for sterile supplies. The office surveyed 18 sterile storage areas that were dirty, and five were improperly doubling as offices or patient care spaces.
• Organizational issues leaving $15 million worth of supplies unaccounted for. While this doesn’t mean the equipment is “necessarily missing,” the report states, it puts government assets in danger of going missing or unused.
• Critical leadership vacancies that will make addressing these issues difficult. For example, the center has been without a permanent Associate Medical Center Director for nearly a year and a half.
In order to address these issues, the OIG recommended the center make several immediate changes, including implementing an “effective inventory management system” and ensuring that all necessary medical supplies are available.
This afternoon, the Department of Veterans Affairs responded to the report in a statement, thanking the OIG “for its quick work” reviewing the center and announced that the medical center director has been removed from his position. Dr. Charles Faselis has been named the acting medical center director for the D.C. VA Medical Center for the time being, according to the department.
The Department of Veterans Affairs also noted that it “considers this an urgent patient-safety issue” and that it is “conducting a swift and comprehensive review” into the findings. "If appropriate, additional disciplinary actions will be taken in accordance with the law," the statement concluded.
The OIG notified the VHA of the issues on March 30. The VHA has since established an incident command center and temporarily assigned staff to address the issues. But the report released today called these actions “short term and potentially insufficient.”
The OIG will release a final report with more recommendations when its inspection is complete.
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