The Veterans Affairs hospital in Washington, D.C., is so disorganized and understaffed that operations were delayed and patients put at serious risk, inspectors reported.
Staff have had to borrow equipment from private hospitals, plunder supplies and use their own purchase cards to buy essential equipment, the Office of Inspector General (OIG) report found.
Supposedly sterile equipment was stored in hot, dusty closets and tens of thousands of dollars of supplies were stockpiled without any inventory, the OIG report says.
“OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk,” the report reads.
The VA fired the medical center director. “The department considers this an urgent patient-safety issue,” it said in a statement.
“Effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties,” it added. “Col. Lawrence Connell, U. S. Army (Ret), has been named the Acting Medical Center Director for the D.C. VA Medical Center.”
The OIG said it inspected the VA medical center after an anonymous tip off.
It found a long list of problems.
“The Medical Center placed patients at unnecessary risk by failing to ensure that appropriate medical supplies and equipment were available to providers when needed; that recalled supplies or equipment were not used on patients; and that sterile supplies were stored appropriately,” the report reads.
“Four prostate biopsy surgical procedures were canceled on April 25, 2016 because prostate biopsy guns were out of stock,” it added. A nurse concerned enough about inventory recommended to the medical center director that operating rooms “stand down” until inventory problems were fixed.
“The Medical Center placed patients at unnecessary risk by failing to ensure that appropriate medical supplies and equipment were available to providers."
“As recently as March 15, 2017, the Medical Center ran out of bloodlines for dialysis patients on the second shift—they were able to provide dialysis services to those patients only because staff borrowed bloodlines from a private hospital,” it adds.
“On March 29, a nurse emailed the patient safety manager, reporting that during an acute episode, she needed to provide oxygen to a patient. The floor was out of oxygen nasal cannulas (tubing that fits into a patient’s nose and provides oxygen). The nurse was able to use one found on the crash cart, but reported the shortage as a risk to patient safety.”
In 2007, the military's flagship Walter Reed hospital in Washington was found to be a mess. It was closed in 2011 and its staff and equipment transferred to the former Naval Medical Center in nearby Bethesda, which was renamed the National Military Medical Center.
The OIG is an independent agency at the VA, set up to provide objective oversight. The report found 194 patient safety reports at the VA medical center since the beginning of 2014.
The inspection found 18 of 25 storage areas for supplies were dirty and that $150 million in equipment or supplies had not been inventoried in the past year.
And there are not enough staff to handle these problems. “There are numerous and critical open senior staff positions that will make prompt remediation of these issues very challenging,” the report reads.
President Donald Trump appointed Dr. David Shulkin, former undersecretary of health at the VA, to head the giant department. The VA takes care of 9 million veterans at 1,700 different hospitals and clinics.