Report: Patients ‘at risk’ at DC VA medical center

WASHINGTON — An investigation into the D.C. Veterans Affairs Medical Center uncovered serious issues regarding the handling of medical equipment, including persistent shortages and supposedly sterile supplies being stored in dirty and cluttered conditions.

The lapses “placed patients at unnecessary risk,” VA Inspector General Michael Missal wrote in the April 12 interim report.

The report prompted the VA to remove the medical center’s director from duty and place him on administrative duties, the agency said in a statement Wednesday afternoon. “The department considers this an urgent patient-safety issue,” the statement said.

According to the watchdog report, the center frequently ran out of supplies, ranging from special equipment for dialysis treatments and vascular surgery to common supplies such as oxygen tubes and alcohol pads. The shortages forced the center to cancel some patient procedures.

The conditions at the Northwest D.C. medical center were so concerning, investigators took the step of publishing their report while their review was still going on.

“We thought it was important for the public, veterans and others to know of this situation, and that’s why we issued our interim report,” Missal told WTOP in an interview.

The full investigation will determine whether patient harm resulted from any of the shortcomings, the report stated. For now, “It’s too early for us to make those kind of findings,” Missal said. “Clearly, patients were impacted by this. Procedures were postponed; procedures were canceled. But we haven’t yet identified the specific risks to an individual patient.”

The investigation was spurred by a March 21 anonymous complaint to the IG.

The report found there was no formal method of inventorying supplies at the medical center. All told, more than $154 million worth of medical equipment was unaccounted for over the past year, according to the report.

Investigators also inspected 25 sterile storage areas and found 18 of them were dirty.

“That means dust, dirt, used equipment,” Missal said.

Missal’s report said VA headquarters knew of the shortcomings since at least January 2017 when officials from the central office made a site visit.

The center is also plagued by a number of “critical” shortages in its leadership, the report found. Vacant positions include the center’s associate director, the chief of human resources, the chief of the business office, the chief of mental health and the chief of radiology.

The IG urged VA officials to “take immediate action that necessary supplies and equipment are available in patient care areas,” put in place an effective inventory system and expedite hiring to fill vacancies.

WTOP’s Dick Uliano contributed to this report. 

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