Systematic problems at the D.C. Veterans Affairs Medical Center put patients at risk for years, with problems including unsterile conditions, a lack of medical supplies and unsecured patient documents, according to a scathing inspector general report released Wednesday.
There was no evidence anyone died because of the issues, the inspector general added, crediting “committed healthcare professionals.”
“Failed leadership at multiple levels within VA put patients and assets at the D.C. VA Medical Center at unnecessary risk and resulted in a breakdown of core services,” Inspector General Michael Missal said in a written statement upon release of the report. “It created a climate of complacency that allowed these conditions to exist for years. That there was no finding of patient harm was largely due to the efforts of many dedicated healthcare providers that overcame service deficiencies to ensure patients received needed care.”
Wednesday’s report is the latest controversy for the VA, where Secretary David Shulkin is fighting off allegations of misusing taxpayer dollars and an internal rebellion by some Trump appointees unhappy with his leadership.
In response to Wednesday’s report, Shulkin pledged system wide changes, as well as changes at the D.C. center.
“It is time for this organization to do business differently,” Shulkin said at a news conference at the D.C. Medical Center. “These are urgent issues and many of these issues are unacceptable.”
Investigators blamed those officials’ failure to fix the issues on “a culture of complacency” at the VA and the Veterans Health Administration (VHA).
“In interviews, leaders frequently abrogated individual responsibility and deflected blame to others,” the report said. “Since 2013, there were reports and documentation of many of these problems that leaders at the medical center and its oversight entities, including the Veterans Integrated Service Network (VISN) 5 and the VHA, failed to adequately address. … Despite the many warnings and ongoing indicators of serious problems, leaders failed to engage in meaningful interventions or effective remediation.”
Examples of the problems identified in the report include medical staff scrambling to find supplies to conduct procedures after patients had undergone anesthesia and running across the street to a private-sector hospital to borrow supplies mid procedure. Surgeons sometimes used instruments they had on hand, rather than the ones they were most comfortable with, the report added.
In addition to a lack of accurate inventory, instruments were also unavailable because of ineffective sterile processing, according to the report. For example, one surgery was canceled after the patient was already under anesthesia because the required retractor had not been sterilized since its use a week earlier.
Investigators also found more than 1,300 boxes of unsecured records from two warehouses, the hospital basement and a trash dumpster. Of those, 81 percent contained confidential patient information.
Shulkin, who served as under secretary for health from 2015 to 2017, told the inspector general he “does not recall” being alerted to the issues when he under secretary, according to the report.
At Wednesday’s press conference, Shulkin said he’s installing new leaders at 20 medical centers across the country, including in D.C., Maryland, New England, Phoenix and Virginia.
Shulkin described his staffing announcements as “the start of a restructuring of VA affairs,” adding the D.C. issues represent a “a failure of every level.”
“It’s unacceptable to me,” he said. “Fortunately this has not led to any known patient harm.”
Shulkin has been embattled since last month’s inspector general report on a trip to Europe he took last year. That report accused him of misusing taxpayer dollars by spending the majority of the trip on sightseeing instead of the conducting official business, having a VA employee use official time acting as a personal travel planner and inappropriately accepting Wimbledon tennis match tickets.