VA ignored dangers at D.C. hospital for years
Officials informed of shortfalls that put patients at risk, wasted money
WASHINGTON – Department of Veterans Affairs officials at nearly every level knew for years about sterilization lapses and equipment shortfalls at the VA Medical Center in Washington, but they were either unwilling or unable to fix the problems, an inspector general’s investigation found.
Local, regional and national officials had been informed of the problems repeatedly since 2013, but investigators concluded “a culture of complacency and a sense of futility pervaded offices at multiple levels.”
“In interviews, leaders frequently abrogated individual responsibility and deflected blame to others,” the investigation report says. “Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions of effective remediation.”
The investigation found clinicians put patients under anesthesia before realizing they didn’t have equipment to perform scheduled procedures. In some cases, they canceled and redid surgeries later. In others, they ran across the street to a private-sector hospital to borrow supplies during procedures.
Investigators also found more than
1,000 boxes of unsecured documents that contained veterans’ personal information — including medical records — in storage facilities, the basement and a dumpster.
The hospital paid exorbitant amounts for supplies and equipment, including $300 per speculum that could have been purchased for $122 each, and
$900 for a special needle that was available for $250.
In one case, the hospital rented in- home hospital beds for three patients for three years — at a total cost of $877,000. The beds could have been bought for $21,000.
Investigators did not find evidence that VA Secretary David Shulkin or his top deputies had been informed of the problems.
Shulkin fired the Washington medical center director last year after the inspector general issued an emergency preliminary report concluding that patients were in imminent danger at the facility. He also dispatched teams of specialists from headquarters to inventory and ensure adequate supplies were available to treat patients.
In their response to the new inspector general’s report, VA officials said the agency has purchased more than $3 million worth of surgical instruments, instituted a reliable inventory system, and is seeking to clarify lines of authority and accountability.
“As we move forward, we are putting in place a reliable pathway” for staffers at all levels to “escalate high-priority concerns to senior leadership for prompt action and follow up,” wrote Carolyn Clancy, executive in charge of the Veterans Health Administration. “This is woven into our ongoing modernization efforts. I am dedicated to continued and sustained improvement and incorporating lessons learned across our network.”
In some cases, the report found, clinicians at the VA Medical Center in Washington ran across the street to a privatesector hospital to borrow supplies during procedures.