-- Sterile supplies kept in dirty facilities, crucial equipment left out of stock, $15 million worth of untracked materials and insufficient leadership in place to enact changes -- this perilous picture of inadequate medical care prompted the Department of Veterans Affairs’ internal watchdog to release a rare preliminary report today on a medical center serving more than 98,000 veterans in the nation’s capital.
While the OIG is continuing to survey conditions at the center, it released a preliminary report “given the exigent nature of the issues ... identified and the lack of confidence in VHA [Veterans Health Administration] adequately and timely fixing the root causes of these issues.”
The OIG has not yet identified any patients directly harmed by the conditions, but the inspection so far has identified several issues detailed in the report, including:
In order to address these issues, the OIG recommended the center make several immediate changes, including implementing an “effective inventory management system” and ensuring that all necessary medical supplies are available.
This afternoon, the Department of Veterans Affairs responded to the report in a statement, thanking the OIG “for its quick work” reviewing the center and announced that the medical center director has been removed from his position. Army Col. Lawrence Connell has been named the acting medical center director for the D.C. VA Medical Center for the time being, according to the department.
"It was determined that naming an acting director from outside the facility would allow leadership to concentrate on addressing the many challenges identified in the OIG report, without compromising the ongoing internal review," the department wrote in a statement.
The Department of Veterans Affairs also noted that it “considers this an urgent patient-safety issue” and that it is “conducting a swift and comprehensive review” into the findings. "If appropriate, additional disciplinary actions will be taken in accordance with the law," the statement concluded.
The OIG notified the VHA of the issues on March 30. The VHA has since established an incident command center and temporarily assigned staff to address the issues. But the report released today called these actions “short term and potentially insufficient.”
The OIG will release a final report with more recommendations when its inspection is complete.