A troubling new report by the Veterans Affairs Department’s inspector general suggests that the only thing worse than having to wait too long for admission to some VA hospitals or medical centers is to actually get in.
Just when it appeared that the VA was bouncing back from a three-year old scandal over hundreds of people dying while awaiting to be admitted to VA health care centers throughout the country, the Inspector General issued a scathing interim report Wednesday on outrageous patient treatment at the main health care facility for veterans in the nation’s capital.
As The Washington Post first reported, conditions are so bad at the Washington, D.C., veterans medical center that doctors have had to abruptly stop operations and dialysis treatments in the past year because of lack of medical supplies. Meanwhile, nurses were seen running through the hospital in a desperate search for nasal oxygen tubes during an emergency.
Just earlier this month, the operating staff had to halt vascular surgeries because they had run short of patches used during the procedures. Those shocking incidents occurred after staff members had requested a resupply two weeks before. In all, the report cited nearly 200 other instances in which equipment and supplies shortages threatened patient safety.
Inspector General Michael J. Missal swung into action after receiving a complaint March 21 from a whistle blower who described equipment and supply issues at the medical center that potentially put patients in harm’s way. While repeated visits to the site by IG investigators failed to uncover any adverse patient outcomes, Missal was furious that these problems had been known to Veterans Health Administration (VHA) senior management for some time “without effective remediation.”
“We have not seen anything quite like this at a VA facility,” Missal told The Washington Post. “They have no inventory system. They don’t know what they have or what they are going to need.”
Among other findings in Missal’s report:
- Nothing had been done to make sure that supplies and equipment that were subject to patient safety recalls were not used on patients.
- Little was done to keep the hospital clean. Eighteen of the 25 sterile satellite storage areas for supplies were filthy.
- Over $150 million worth of equipment or supplies had not been inventoried in the past year and were not accounted for.
- The lease on a large warehouse brimming with non-inventoried equipment, materials and supplies expires on April 30, just weeks from now. Currently, there is no effective plan to move the contents of the warehouse by that date.
- There are numerous and critical open senior staff positions that will make prompt remediation of these issues very challenging.