VA General Inspector Finds Veterans at D.C. VA in ‘Imminent Danger’
The findings included a surgeon using outdated equipment and the facility used outdated chemical strips, which voided 400 sterilization tests.
The general inspector for the VA found that veterans at the Department of Veterans Affairs Medical Center in Washington, D.C., face “imminent danger” due to the horrific conditions. USA Today reported:
The VA inspector general found that in recent weeks the operating room at the hospital ran out of vascular patches to seal blood vessels and ultrasound probes used to map blood flow.
The facility had to borrow bone material for knee replacement surgeries. And at one point, the hospital ran out of tubes needed for kidney dialysis, so staff had to go to a private-sector hospital and ask for some.
The hospital, which serves more than 98,000 veterans in the nation’s capital, lacks an effective inventory system, the inspector general determined, and senior VA leaders have known about the problem for months and haven’t fixed it. Investigators also inspected 25 sterile storage areas and found 18 were dirty.
USA Today also listed a few other points from the report:
• In February 2016, a tray used in repairing jaw fractures was removed from the hospital because of an outstanding invoice to a vendor.
• In April 2016, four prostate biopsies had to be canceled because there were no tools to extract the tissue sample.
• In June 2016, the hospital found one of its surgeons had used expired equipment during a procedure
• In March 2017, the facility found chemical strips used to verify equipment sterilization had expired a month earlier, so tests performed on nearly 400 items were not reliable
The inspector general rarely releases preliminary reports. But Inspector General Michael Missal found the hospital in such a horrible state that he had no other choice:
“Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues,” VA Inspector General Michael Missal wrote.
Missal stated that the findings “placed patients at ‘unnecessary risk,'” but the office does not know yet if any of the practices harmed patients.
After Missal notified officials, the VA built “an incident command center on March 30,” which included “logistics specialists, technicians and managers to fix the problems. But Missal said the officials must do more:
Such actions, Missal said, are “short term and potentially insufficient to guarantee the implementation of an effective inventory management system and address the other issues identified.
“Further, shortages of medical equipment and supplies continued to occur…, confirming that problems persisted despite these measures,” he wrote.
The VA placed the hospital’s director Brian Hawkins on administrative duty. USA Today reported that VA Secretary David Shulkin “welcomes outside oversight with hopes it will help him fix the beleaguered agency.”
Past Scandals
Beleaguered is a proper way to describe the VA, which has had one too many scandals in recent years. Here are a few.
Suicide hotline
In March, the inspector general found that officials have not made the necessary changes to the suicide hotline for veterans. Thing is, the office found these problems last year and the VA promised changes would come by the end of September. Officials had not done anything by December.
North Carolina VA left veterans on the floor
The Durham VA in Durham came under fire when Marine veteran Stephen McMenamin and his wife Hanna posted photos on Facebook of veterans lying on the floor and witnessed employees ignoring those in pain:
“It was very upsetting,” Stephen McMenamin said. He and his wife said they saw a handful of older veterans mistreated and ignored during the seven hours they were at the hospital, including an aged-veteran in a wheelchair.
“He had been sitting there for quite some time groaning and convulsing in pain,” McMenamin said. “Almost to the point of where he was falling out of his wheelchair.”
“He was visibly in pain,” said Hanna. “And I think the thing with that that disturbed me so much was that there were people just sitting there acting like nothing was happening and he was sitting right in front of them and they were not even acknowledging that it was happening.”
VA hospital kept a dead veteran in a shower for 9 hours
The Bay Pines VA Healthcare System in Tampa Bay, FL, left the body of a veteran in the shower for nine hours before transporting him to the morgue. The investigation found that some of the “hospice staff violated hospital and Veterans Affairs policies by ‘failing to provide appropriate post-mortem care,’ including proper transportation of a body to the morgue, according to the report by the hospital’s Administrative Investigation Board.”
Spokesman Jason Dangel told the publication that the hospital has “ordered retraining and a change in procedures.” He also said the hospital officials took “appropriate personnel action,” but he did not say if the officials fired or disciplined those at fault.
Wisconsin VA dentist may have infected patients with HIV, Hepatitis
Last December, officials found that a dentist at the VA in Tomah, WI, may have infected up to 600 veterans with HIV, hepatitis, and other diseases. The dentist used his own equipment and also washed and reused it. The VA should only use “sterile and disposable equipment.”
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Comments
Eliminate the VA, and give soldier’s good private insurance – not the crap that is obamacare (from which Congress and the President are exempt.)
Billions will be saved, and wounded and ill soldiers will be happier.
I’m a veteran who had to start going to the V.A. after Obamacare raised my premiums and deductible. My private physician advised against it.
Thanks, Obamacare.
Send Congresscritters to VA.
And make their families us VA.
Nothing about the VA is going to change until the entire culture of accountability changes.
If a private hospital had been that unsanitary it would have been shut down by HHS in a heartbeat. But since its VA its just business as usual.
Trump better get on board fast. It’s time for action. No time for delay. Do it Donald! I’m counting on you, you said you’d do something, now please fix this mess.
Many years ago I worked as a physician in several VA hospitals. One was the D.C. VA. The D.C. VA was one of the earliest adoptors of a computerized ordering system and that was because the staff of the hospital were hopelessly irresponsible and incompetent. Not to mention surly to white people like me. There were resident teams which staffed the hospital from the area’s medical schools (GW, Georgetown, and Howard as well as some house staff who belonged to the VA itself. When the Howard team arrived, the intern looked around and said, “I’m not working in no white man’s hospital!” (notwithstanding the fact that the vast majority of patients and employees were not white) and walked out. His resident said, “I’m not working alone” and walked out. The rest of us had much more work to do.
I’m sure the D.C. VA has not improved with time.
The basic truth is that the VA system is part of the government and the only thing the government does with any semblance of competence is to collect taxes. The veterans would be best served in the private sector, though, I must add, the vets themselves are not necessarily innocent. Many of them have malingered, exaggerating their symptoms in times before their VA case reviews, hoping to increase their percentage of “disability” in order to increase their disability pensions.
Though I have had no connection with the VA in years, I have no doubt that the entire system is thoroughly corrupt. No news emanating from the VA in recent decades has altered my long held opinion.
How many examples do we need? Healthcare is like any other business in the world— it functions better when the free market rules. As Harvard economist Dr. Michael Porter wrote a decade ago, where there is transparency of price and knowledge of quality, patients and doctors always make the best decisions they can.
If the dialysis cost “X” and you got 20 infections at hospital A and 3 at a hospital B, you’d vote with your feet. If hospital C had 5 infections but cost 1/2 X, you make the value decision that is appropriate for you. That’s what we do now, for every purchase we make, and it works out just fine.
Lousy hospitals would wither away and die, good ones would get busier, and with more patients and more money, get even better. For this to happen, the price has to be known, the quality accurately measured. Figure out a way for everyone to acquire catastrophic insurance and a health savings account and get the government out of the equation as fast as you can.
You said you would, Mr. Trump. Maybe the voters will take care of Ryan so you can get what we all need in front of congress. You could write a workable bill in less than 100 pages and free up thousands of bureaucrats so the cash could go to actual medical care. It can be done, and there’s no time like the present.
When, oh when, will some high level VA officials be held accounbtable for any of this. I mean lose your job and pension accountable, and if possible criminal conviction accountable. To quote John Lennon: “I know I’m a dreamer, but I’m not the only one.”
I did two tours in Vietnam in the Corps and was sprayed like a car wash with agent orange. I tried to get help from the Louisville, KY VA and have finally, after two years, given up. If all you want is a nail clip, they got you covered. Not much else. And what attitudes.
Dealing with the VA can be like pulling your own teeth. The first step is to find a good service officer (DAV, American Legion, and VFW) and have them get a copy of your SRB. The Marine Corps is very good at record keeping and my SO was able to get mine that went back to my first clothing issue at MCRD.
There are diseases the VA will accept just because you were ashore. I think the easiest way to deal with the VA about those diseases are to get them diagnosed by an outside doctor and submit the paperwork. That eliminates the long wait time to see a VA doctor.
I’m not completely up to speed about the Choice Program, but if you have one of those cards you can ask to see an outside provider if you live a long distance away from the VA facility or have a long wait time to see a doctor.
To quote Maj Lloyd Williams (MH WW1)….Retreat Hell, we just got here. Good luck, Brother.
The fact that the VA continues to be a problem for our vets is a national disgrace. Give them vouchers to go where they choose and shut down these disgusting places.
Multiple administrations have failed to fix the problem – no reason to believe anything will change much now or in the future. Government can’t fix what it caused.
After getting out of the Army I took the income based VA health coverage while I was a college student. In 2003, getting hit by a car resulted in a trip to the Hines VA emergency room. I had a lot of pain from two broken ribs, but it was the onset of left arm numbness that got me to go to the ER. After an 8 hour wait in the emergency room, when the doc did see me, it was nothing more than a 30 second exam. he had me hold my left arm up and pushed it back down. He wrote a script for naproxen and told me there was nothing to do with a broken rib. That’s it. no x-ray or imaging of any kind. That whole time the ER saw 6 or 7 patients including those that were in the waiting room before me.
Years later my PCP finds an untreated spinal fracture that healed on it’s own. It was just above the broken ribs and likely the source of my arm numbness (which resolved luckily)