Dirty storage areas, staffing deficiencies, and supply shortages that cause procedures to be delayed or canceled are some of the findings in an interim report that concluded patients' safety is in jeopardy at the VA Medical Center in Washington, D.C., according to the Department of Veteran Affairs Office of the Inspector General.
The report released Wednesday prompted the removal of medical center director Brian A. Hawkins. Hawkins has been assigned temporarily to administrative duties with more potential disciplinary actions to come, according to CNN.
The OIG said they "became aware of potentially serious patient care issues" at the hospital, and deployed their Rapid Response Team to investigate on March 29. They notified the VA of their findings the next day, which included "a number of serious and troubling deficiencies at the VAMC that place patients at unnecessary risk."
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The Veterans Health Administration senior management had known about some of the issues "for some time" without taking effective corrective actions, the OIG said in a statement.
The issues include the absence of an effective inventory management system for medical supplies and equipment used in patient care, having no system to ensure recalled equipment and materials are not used on patients, dirty supply storage areas, $150 million in equipment that has not been inventoried or accounted for, and critical senior staff vacancies that impede the correction of the hospital's numerous issues.
The report showed that 18 of the 25 sterile satellite storage areas for supplies were dirty, which could pose a threat of contamination.
Supply shortages also impacted patient care. In February of 2016, a bone tray used in jaw fracture surgeries was removed from the hospital due to outstanding bills to the vendor. A procedure was subsequently delayed because of the removal. In April 2016, four prostate biopsies procedures were canceled because the hospital was out of prostate biopsy guns.
In June 2016, the hospital discovered that one of its surgeons used expired surgical equipment on a patient during a procedure. After ruling that the lack of an inventory management program has caused the mistake, the medical center moved to require nursing staff to perform inventory rounds each month to remove expired supplies.
"VA did take several immediate actions to address the issues such as establishing an incident command center, temporarily assigning an additional logistics chief, technicians, and Veterans Integrated Service Network staff to the facility on a temporary basis. OIG feels that these actions are short-term and insufficient to ensure the implementation of an effective inventory management system at the VAMC. Shortages of medical equipment and supplies continued to occur while our OIG team was onsite, confirming that correcting the problems is going to require a coordinated long-term effort by VA."
The OIG said their work with the VAMC is ongoing, and a final comprehensive report will be issued.