Federal officials ordered an operating room at the Washington DC VA Medical Center shut down late last week after the latest in a series of maintenance issues that have plagued the facility in recent months.
The temporary shutdown lasted approximately three hours, according to a U.S. Department of Veterans Affairs spokesman.
An air valve failed, the agency said, triggering a spike in temperature and humidity in the operating room, which is one of six inside the giant VA Medical Center on Irving Street in Washington, D.C.
The emergency shutdown required the postponement of surgeries and raised new questions about the operations of the major medical facility, which treats about 98,000 local military Veterans a year. An agency spokesman said two eye surgeries were postponed because of the malfunction. Repairs have since been completed, the spokesman said.
The shutdown occurred weeks after a series of other maintenance and safety problems and a management shakeup at the medical center were revealed by a News4 I-Team investigation. Records obtained by the I-Team showed the agency hired a contractor to fix potentially unsafe floor cracks in the facility’s surgery department in March. VA officials also ordered repairs of holes in the walls of the facility’s “center core areas,” completing the project in mid-February.
The facility suffered a cockroach infestation and a lack of sanitary conditions in its food service areas in 2015, according to federal records reviewed by the I-Team. An agency spokeswoman told the I-Team the problems have since been remedied.
In May, an I-Team investigation revealed the body of a patient went undiscovered for nearly two days in the parking lot outside the medical center. The cause of death has not been determined, according to federal officials who spoke with the I-Team. The agency acknowledged it will investigate the time lag between the death and discovery of the man.
The string of recent problems closely preceded a major management shakeup at the medical center. The agency’s longtime DC VA Medical Center director Brian Hawkins was reassigned to a position at VA headquarters in April. Days after questions were raised by the I-Team in June about the reassignment, the agency announced it had ordered a disciplinary action against Hawkins but would not specify the type of disciplinary action.
The I-Team’s reporting and a separate review by the U.S. Department of Veterans Affairs Office of Inspector General triggered a congressional investigation into the DC VA Medical Center.
The inspector general review, released in April, revealed broader safety and management problems at the DC VA Medical Center, including dirty sanitary storage areas, supply shortages and more than $150 million in unaccounted for equipment and supplies.
Eighteen of the medical center's 25 sterile storage areas were found to be dirty, according to the report by the VA Office of the Inspector General. In five storage areas, the clean equipment and supplies were mixed with the dirty. Seventeen areas lacked ways to monitor pressure, temperature and humidity.
The medical center lacked an effective inventory system, and $150 million in equipment and supplies were not inventoried in the past year. Meanwhile, the lease on a large warehouse of non-inventoried items expires at the end of the month with no plan to relocate the contents and staffing constraints could make it difficult to address the situation.
Also, no effective system was in place to ensure recalled supplies and equipment were not used on patients, according to the report.
The unsanitary conditions and lack of attention to safety recalls placed patients at risk, as did a failure to ensure availability of supplies and equipment when needed, the report said. For example, a nurse reported a floor was out of tubes used to provide oxygen when a patient was in need. On a couple of occasions in March, the medical center ran out of bloodlines for treating dialysis patients.