OIG investigating Washington D.C. VA Medical Center
Yesterday, the Office of Inspector General (OIG) issued a rare interim report about their ongoing investigation of the Washington, D.C. VA Medical Center. The report revealed, among other things, dirty sanitary storage areas, more than $150 million in unaccounted for equipment and supplies, and supply shortages that could affect treatment of patients.
On March 21, OIG received a confidential complaint about the D.C. VA Medical Center describing equipment and supply issues serious enough to potentially compromise patient safety. On March 29, OIG deployed a Rapid Response Team to assess the allegations.
What did they find?
Eighteen of the 25 sterile storage areas for supplies at the VA Medical Center were found dirty. Many of the areas contained improperly stored equipment. Five of these storage areas mixed clean with dirty equipment or supplies; seventeen lacked a method to monitor environmental factors, like temperature and humidity, that could affect supplies; and five areas were being used not only as storage but as office and patient care spaces.
Investigators found that the Medical Center had no inventory system in place to monitor the availability of medical equipment and supplies since May of 2015. Instead, logistics staff reported that they used email to communicate information about equipment and supplies, significantly raising the risk of human error.
The OIG report estimates that over $150 million in equipment and supplies have not been inventoried in the past year. The lack of an inventory system means that hospital supplies and equipment might be used after expiration or safety recall and that hospital staff may not be able to locate the proper supplies when patients need them.
Effect on patients
Though the OIG reported no evidence of direct patient harm, supply shortages put VA patients at unnecessary risk. Since 2014, the Medical Center has recorded 194 patient safety reports resulting from the unavailability of equipment or supplies. One nurse reported that, when a patient was having an acute episode, the floor was out of the tubes needed to provide oxygen to the patient. Another report claims that when the Operating Room ran out of the devices used to prevent blood clots during surgery, surgery proceeded without them.
Other supply issues have resulted in the canceling of surgical procedures due to lack of equipment, the use of expired surgical equipment in a surgical procedure, and the removal of equipment from the facility due to outstanding invoices.
The OIG report also noted that the Medical Center has a large warehouse stocked full of non-inventoried equipment, materials, and supplies costing an estimated $15 million. The lease for the warehouse expires on April 30, 2017 and there is reportedly no effective plan to move the contents.
The resolution of these supply and sanitation problems is further hindered by numerous open senior staff positions. The VA Medical Center has operated without a permanent Associate Medical Center Director since at least December 2015. Also remaining open are other critical management positions. Open positions include Associate Director for Patient Care Services; and Chiefs of Human Resources, Mental Health, Police, and Radiology.
Because the Chief of Human Resources position is vacant, the Medical Center has virtually no Human Resources Department. At the beginning of March, all new hiring had to be temporarily taken over by the Human Resources Department of the VA Maryland Healthcare System.
The Medical Center has no current Logistics Officer nor Deputy Chief Logistics Officer. Despite being authorized for 42 full time employees, the logistics department employs only 33. A 2015 report demonstrated a 50 percent vacancy rate in non-expendable equipment and supply positions.
This investigation is ongoing
The OIG continues to investigate the D.C. VA Medical Center and promises a full report once the investigation concludes. In the meantime, VA reassigned the current director. The D.C. VA Medical Center serves more than 98,000 veterans in the Washington, D.C. metropolitan area.