The VA in Tomah, Wisconsin, has become entangled in a scandal after a dentist may have infected veterans with hepatitis or HIV:

Nearly 600 veterans who received care at the Tomah VA may have been infected with several types of disease due to violations in infection control procedures.

VA administrators made the announcement Tuesday afternoon at a press conference.

The Tomah VA says it’s in the process of notifying 592 veterans that they may be infected with Hepatitis B, Hepatitis C, or HIV after they received care from one particular dental provider.

Acting Medical Center Director Victoria Brahm said the dentist was using his own equipment, then cleaning it and reusing it, which violates the VA’s regulations.

The dentist’s new assistant noticed the dentist cleaning and reusing his equipment and reported the violation. The VA has said it only “uses sterile and disposable equipment.” From News 8000:

Brahm said the dentist had one assistant for most of the time, but it was a different assistant who reported the issue.

“He had a replacement dental assistant, and she noted this particular piece of instrument being used,” Brahm said. “She reported it the next day, Oct. 20, to the dental chief who reported it to senior leadership. We took action Oct. 21.”

The VA requires dental burs to be disposable.

“He brought in his own burs and cleaned them with Virex solution, salt and a wipe which is nothing we endorse,” Brahm said.

The hospital has offered free screenings for the veterans at risk. Experts believe “the risk of infection is very low.” At least two dozen veterans have taken up the offer and received blood tests. WEAU News reported:

That dentist has been removed from patient care and is now working in an administrative role.

The VA also referred the case to the inspector general for assessment of any criminal charges.

“It was purposeful that he was violating VA regulations,” Brahm said. “During all of the orientation, he used all of our equipment. He used it appropriately, so it was very purposeful from what we found in our investigation that he knew exactly what he was doing, and preferred to use his own equipment against procedure.”

This scandal comes at a time when the Tomah VA has tried to improve its image:

“There was culture issue here, one of non-psychological safety, one of opioid abuse,” the center’s acting director, Victoria Brahm, said. “Those things are changing.”

Part of that change, Brahm said, is weeding out employees that put veterans at risk, like the dentist who she said knowingly went against the VA’s standards from October 2015 to October of this year.

Brahm said the dentist had one assistant for most of the time, but it was a different assistant who reported the issue.

In August, the family of Marine Jason Simcakoski filed a wrongful death lawsuit against the Tomah VA after he died “from a mixture of drugs that included opioids” in August 2014. He sought treatment for his mental health.

The VA fired chief of staff Dr. David Houlihan and reassigned its medical center’s director.

Some veterans at the VA called Houlihan the “candy man” because “of his supposedly easy and widespread distribution of painkillers to his patients.” A report from the Senate Homeland Security and Governmental Affairs Committee stated that Houlihan and Deborah Frasher, his nurse practitioner, “may have been ‘impaired’ themselves during a 2012 interview.