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.”