VA Responds to IG Report on Health-Care Inspection at D.C. VA Medical Center
WASHINGTON — Today, the Office of Inspector General (OIG) released an interim summary report titled Healthcare Inspection – Patient Safety Concerns at the Washington, D.C. VA Medical Center (VAMC), Washington, D.C.
The Department of Veterans Affairs thanks the OIG for its quick work reviewing the D.C. VAMC. The department considers this an urgent patient-safety issue.
Effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties.
Dr. Charles Faselis has been named the acting Medical Center Director.
VA is conducting a swift and comprehensive review into these findings. VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.
On March 21, 2017, a confidential complainant forwarded to the Office of Inspector General(OIG) documents describing equipment and supply issues at the Washington D.C. VA Medical Center (the Medical Center) sufficient to potentially compromise patient safety. OIG promptly reviewed the documentation.
On March 29, 2017, OIG deployed a Rapid Response Team to assess the allegations. OIG’s team conducted interviews, collected documents, and conducted a physical inspection of the Medical Center’s satellite storage areas on March 29–30, 2017. The team returned for an additional site visit on April 4–6, 2017, and is on-site for a third inspection at the time of this report’s publication.
OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk. Although we have not identified at this time any adverse patient outcomes, we found that:
there was no effective inventory system for managing the availability of medical equipment and supplies used for patient care;
there was no effective system to ensure that supplies and equipment that were subject to patient safety recalls were not used on patients;
18 of the 25 sterile satellite storage areas for supplies were dirty;
over $150 million in equipment or supplies had not been inventoried in the past year and therefore had not been accounted for;
a large warehouse stocked full of non-inventoried equipment, materials and supplies has a lease expiring on April 30, 2017, with no effective plan to move the contents of the warehouse by that date; and
there are numerous and critical open senior staff positions that will make prompt remediation of these issues very challenging.
At least some of these issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation.
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. We are also including recommendations for immediate implementation.
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