The Department of Veterans Affairs inspector general released a rare interim report Wednesday warning about the dangerous, abysmal conditions that have placed patients at unnecessary risk at the D.C. medical center.
After receiving a complaint March 21, the office of the VA inspector general deployed a rapid response team to the medical center in Washington, D.C., which serves 98,000 veterans.
What investigators found is shocking, and yet, the report confirmed that the Veterans Health Administration knew about this issues and did nothing.
Over the past three years, there were 194 reports of patient safety compromises, due to a lack of equipment.
Investigators discovered that 18 of 25 sterile storage spaces for supplies were dirty. Five other areas had a mix of dirty and clean supplies.
Equipment shortages seemed to touch nearly all areas that suffered from dangerous problems. In one case, the hospital ran out of kidney dialysis equipment and had to ask for the tubes from a private sector hospital. In another case, staff had to borrow bone material for knee replacement surgeries.
In February 2016, equipment used to repair jaw fractures was removed because the VA hadn’t paid the vendor appropriately.
In April 2016, the VA had to cancel four important surgeries because it had run out of the necessary tools.
In June 2016, the medical center used expired equipment during a surgery, which occurred because there was no inventory management system in place.
On April 30, 2017, the VA’s lease of a warehouse for equipment storage expires, and staff who were interviewed didn’t believe all the equipment could be emptied before that deadline.
While the report noted that the medical center had placed patients at risk, inspectors were not able to determine at this time if any patients were harmed as a result of the conditions.
Still, the work is preliminary and the assessment will continue until a final report is published.
“The OIG’s work is continuing and will include an assessment of whether patient harm has resulted from any of these inventory practices in its final report on the Medical Center,” VA inspector general Michael Missal wrote.
The inspector general does not often release preliminary investigations. The last example seems to be from January 2015 when the Phoenix VA was endangering patients because of lapses in urology care.
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