Disarray at VA hospital detailed in new report
By AARON C. DAVIS | The Washington Post | Published: April 13, 2017
WASHINGTON - At the main health-care facility for veterans in the nation's capital, doctors have had to halt operating room procedures and dialysis treatments in the past year because of a lack of supplies, nurses have frantically run through the facility hunting for nasal oxygen tubes during an emergency, and sterile surgical items have been left in dirty or cluttered supply rooms, according to a new report.
Conditions at the Washington District of Columbia VA Medical Center were so troubling that the Department of Veterans Affairs' inspector general released a rare interim report Wednesday saying he is conducting a probe of the facility but did not want to wait for its completion to warn the public.
"We have not seen anything quite like this at a VA facility," said Inspector General Michael Missal. "They have no inventory system. They don't know what they have or what they are going to need."
"Hospitals are typically chaotic places," he told The Washington Post, "but this was the highest levels of chaos. Staff was literally scrambling every day. Sometimes they would have to go to other hospitals to get equipment as a procedure was going on."
Missal said he also had a second motivation for going public: Investigators had determined that VA had known about some of the deficiencies for years, and therefore the inspector general had a "lack of confidence" that the agency would quickly address the problems.
The report had an immediate impact. VA Secretary David Shulkin said he ordered that the head of the medical center be reassigned to duties elsewhere and that a member of his senior staff, retired Army Col. Lawrence Connell, would take over as acting director of the medical center to oversee improvements.
"When I became aware that veterans were at risk, that's when we took immediate action," Shulkin said in a Thursday news conference. "If there are veterans who have been harmed, we are going to find out about that and find the people accountable."
The Washington DC VA Medical Center, a sprawling campus along North Capitol Street and adjacent to the MedStar Washington Hospital Center, provides care to almost 100,000 veterans from across the region.
The investigation into problems at the facility began in March with a tip from a confidential informant, according to the inspector general's report. Most of the problems investigators subsequently found centered on inadequate staffing and scant attention to medical supplies.
The medical center has a 100,000-square-foot storage facility and 25 satellite storage areas containing an estimated $150 million in medical supplies, but staff members have not inventoried materials in more than a year and therefore cannot find items when needed, the report said. In some instances, the facility can't verify whether doctors are using products that may have been recalled or have expired.
A lease on the central facility is set to run out in less than three weeks, and VA appears to have made no provisions for relocating supplies. At 18 of the satellite areas, VA was storing surgical instruments and other items in dirty or cluttered rooms, the report said.
The logistics failures routinely affected patient care, inspectors found.
Last month, the medical center ran out of bloodlines for dialysis treatment and could only perform the procedure by borrowing supplies from a private hospital.
On March 29, a nurse wrote in an email that during an acute episode with a patient, she could not find tubes in her unit's storage area to insert into a patient's nose to provide oxygen.
On April 10, the operating room staff had to halt vascular surgeries because it had run out of patches used during the procedures, despite having requested a resupply two weeks earlier.
Also this week, the inspector general's office learned that other surgical operations were ongoing even though the hospital had run out of compression devices to place on patients' legs to prevent blood clots from forming.
The interim report identified almost 200 instances in which equipment shortages may have affected patient safety.
Shulkin said he was not aware of any instances in which veterans were harmed but promised a digital inventory system would be in place at the D.C. facility by Monday and that care for veterans in D.C. would improve.
Shulkin did not name the medical center director who was relieved of his command, but the center's website Wednesday listed the director as Brian Hawkins. A call to a phone number listed for Hawkins was not immediately returned. Shulkin said it was too soon to assign responsibility for the problems uncovered by the inspector general.
According to the report, several senior positions below medical director, including a chief of logistics, a head nurse and other top slots, had remained vacant, in some cases for years.
VA has temporarily moved human resources responsibilities for hiring for the D.C. medical center to its Baltimore medical center. "Many VA medical centers have a really hard time hiring, but this seems worse than the others," Missal said.
The inspector general said a focus of his investigation will be determining how the situation was allowed to deteriorate and remain that way.
Rep. Tim Walz (Minn.), the ranking Democrat on the House Veterans' Affairs Committee, called on his committee to investigate, characterizing the inspector general's findings as "outrageous and unacceptable."
"When you have systemic failure on this level, management must be held accountable," he said.