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Inspector General Report Shows Widespread Problems at DC VAMC

Bradley Hennings

March 8, 2018

Updated: November 20, 2023


March 8, 2018 – The Office of the Inspector General (OIG) released a 150-page report on March 7, 2018 that shows widespread miscommunication and disorganization at the Washington D.C. Department of Veterans Affairs medical center.

The report details system-wide problems at the medical center since 2013, including a disorganized inventory system, unsterilized surgical utensils, a lack of medical supplies, and a back log of requests for patient medical equipment including prosthetic limbs.

The report released yesterday was preceded by an Interim Report released April 12, 2017. Read our coverage of the Interim Report here.

What Did the Report Find?

The Inspector General found that VA employees misused government charge cards to spend about $92 million on supplies that should be been purchased through vendor contracts at lower prices. The report detailed specifics about the practices at the DC VA, citing canceled surgeries due to lack of supplies or unsterilized equipment, putting patients under prolonged anesthesia while equipment was located, unsecured patient medical records stored in a warehouse and trash bin, and one veteran waiting over a year for a prosthetic limb.

The report unearths a startling picture of the complacency and delays that have become commonplace at the DC VA. OIG found that multiple officials were informed of the issues but did little to intervene.

What Now?

VA Secretary David Shulkin plans to put considerable policy changes into effect in response to the report citing a “failure of the VA system at every level – a failure at the facility level, a failure at the network level and a failure at the central office.” Additionally, the OIG made 40 recommendations that have all been accepted by the VA. The recommendations are meant to remedy the issues uncovered at the DC VA and also prevent similar problems from occurring at other VA facilities.

Shulkin fired the Washington medical center director following the release of the Interim Report and directed specialized teams to make sure that there were adequate medical supplies at the facility to treat patients.

The team who investigated the DC VA noted that no patients died or were physically harmed from the problems outlined in the report. However, patients were put at unnecessary risk and their medical care was affected from cancelled or delayed surgeries and waiting for prosthetics.

Read the full report here.

About the Author

Bio photo of Bradley Hennings

Bradley Hennings joined Chisholm Chisholm & Kilpatrick as an attorney in January 2018 and currently serves as a Partner in the firm. His practice focuses on the U.S. Department of Veterans Affairs (VA) and the U.S. Court of Appeals for Veterans Claims.

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