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Department of Veterans Affairs Inspector General Michael Missal, at a House hearing in March, 2017.

Department of Veterans Affairs Inspector General Michael Missal, at a House hearing in March, 2017. (Stars and Stripes)

WASHINGTON — A government watchdog found the Department of Veterans Affairs medical center in the nation’s capital was putting veterans at “unnecessary risk” by failing to sterilize storage areas and running out of various medical equipment, according to a report released Wednesday.

Quickly after the report came out, VA officials relieved the Washington hospital’s medical director and named an interim director. They named Charles Faselis to the position Wednesday. By Thursday, the appointment changed, and retired Army Col. Lawrence Connell was announced as the temporary medical director.

Charles Faselis has been chief of staff at the Washington VA since April last year. Connell is a senior adviser at the agency.

“After further consideration, it was determined that naming an acting director from outside the facility would allow leadership to concentrate on addressing the many challenges identified in the [Office of Inspector General] report, without compromising the ongoing internal review,” read a statement Thursday from VA officials.

The VA did not name the demoted medical director in its announcement, but the medical center’s website lists Brian Hawkins as holding the position since 2011.

VA Inspector General Michael Missal released the findings, though the investigation began only late last month and is ongoing – a move that is unusual for the office. It states that 18 of 25 sterile storage areas for medical supplies were dirty, and more than $150 million in equipment is unaccounted for.

“Although our work is continuing, we believed it appropriate to publish this [report] given the exigent nature of the issues … and the lack of confidence in [VA] adequately and timely fixing the root causes of the issues,” Missal said in the report.

Senior leadership at the VA’s veterans health administration has known of the issues “for some time” but took no effective action, the report states. Before VA Secretary David Shulkin was appointed to his current position in February, he led the veterans health administration as undersecretary.

During visits as recent as last week, inspectors found the hospital had run out of oxygen tubing, bone cement for prosthetics and devices placed on patients to prevent blood clots during surgery, among other things. When the medical center ran out of bloodlines for dialysis patients, it had to borrow them from a private hospital.

The issues have persisted since at least 2014, the report states. Since January of that year, the hospital recorded 194 patient safety reports related to the unavailability of supplies.

Rep. Tim Walz, D-Minn., ranking member of the House Committee on Veterans’ Affairs, called on the committee late Wednesday to oversee the problem “without delay.”

“The details documented in this report regarding serious patient safety issues at the Washington, DC VA are outrageous and unacceptable,” Walz said in a prepared statement. “When you have systemic failure on this level, management must be held accountable.”

The American Legion announced Thursday that it will hold a town hall-style meeting between veterans in the Washington area and VA officials. Specifics about the meeting weren’t made available Thursday and a date had not been announced.

“The 2.2 [million] members of the American Legion demand that President [Donald] Trump and Secretary Shulkin hold those officials responsible for the gross mismanagement of this facility accountable for their actions,” the group’s National Commander Charles Schmidt said in a prepared statement. “Furthermore, we call on the president and secretary to ensure the safe and efficient management of all VA facilities, and we call on Congress to properly fund the [VA] so that the needs of our nation’s veterans can be fully addressed.”

The inspector general’s office has not determined whether the problems have led to patients being harmed, but it did find instances when procedures were delayed or canceled because of a lack of supplies.

In one instance, a patient’s jaw surgery was delayed. The hospital was missing the necessary supplies because it had an outdated invoice from its supplier, the report states. On four occasions, prostate biopsy procedures were canceled because of out-of-stock equipment.

“VA is conducting a swift and comprehensive review into these findings,” a VA statement said. “VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”

Other equipment was found to be expired, uninspected or improperly stored. In one instance in 2016, VA surgeons used expired equipment on a patient.

Missal wrote the hospital has an underlying issue of managing its inventory.

The inspector general received documentation showing 27,494 items worth about $154.9 million in supplies and equipment in the past year was not inventoried. The finding does not necessarily mean the equipment is missing, the report states, but it’s not tracked as required.

In one document, VA headquarters staff referenced a 100,000-square-foot warehouse full of non-inventoried supplies totaling an estimated $15 million, the report states.

A lease for the warehouse is expected to end April 30, and staff has no plan to move the equipment stored there.

Of its 25 storage facilities, 18 were dirty and five mixed clean and dirty medical supplies.

Missal’s office continues to investigate and will determine whether the problems have harmed patients, he said.

He first sent a “rapid response team” to the medical center March 29, following allegations of equipment and supply issues that were compromising patient safety. The team returned for a site visit April 4 to 6, and is currently on-site again.

Besides problems with equipment and supplies, inspectors also discovered there were numerous, “critical” open senior staff positions at the hospital that will encumber efforts toward improvement. Some of the vacancies were for a chief of logistics, assistant chief of logistics and supply technicians.

The inspector general notified the VA about the problems March 30, and officials responded by temporarily assigning other staff to the hospital and establishing an incident command center. The report described the response as “insufficient.”

“We are particularly concerned that [VA has] been slow to remediate these serious deficiencies,” Missal wrote.

The report listed eight immediate recommendations, including making supplies available at VA health care facilities in the Washington area, implementing an inventory system and hiring for open positions.

The VA on Wednesday placed the hospital’s medical director on administrative duties.

Conservative-leaning Concerned Veterans for America responded that the situation highlights the need for Congress to give Shulkin the authority to quickly fire employees.

Law currently allows federal employees 30 days written notice before they’re fired or demoted, and provides an appeals process.

The House recently passed legislation that would expedite the disciplinary process at the VA. Shulkin has urged the Senate to take up the issue, but it’s uncertain when it will do so.

“The VA did the right thing by relieving the D.C. director from his position, but he’s still being paid by taxpayers and under current law it will be very difficult to terminate him,” said Dan Caldwell, policy director for CVA, in a statement. Twitter: @nikkiwentling

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Nikki Wentling has worked for Stars and Stripes since 2016. She reports from Congress, the White House, the Department of Veterans Affairs and throughout the country about issues affecting veterans, service members and their families. Wentling, a graduate of the University of Kansas, previously worked at the Lawrence Journal-World and Arkansas Democrat-Gazette. The National Coalition of Homeless Veterans awarded Stars and Stripes the Meritorious Service Award in 2020 for Wentling’s reporting on homeless veterans during the coronavirus pandemic. In 2018, she was named by the nonprofit HillVets as one of the 100 most influential people in regard to veterans policymaking.
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