DC VA Medical Center Inspection Finds Dirty Sterile Storage, $150M in Unaccounted for Items and Unavailable Supplies

Veterans Affairs reassigned the director of its medical center in Washington, D.C., after a scathing report revealed dirty sanitary storage areas, more than $150 million in unaccounted for equipment and supplies, and supply shortages that could affect treatment of patients.

Veterans Affairs temporarily assigned the director to administrative duties and named Dr. Charles Faselis acting director.

On Thursday, Veterans Affairs announced Col. Lawrence Connell would serve as acting director, reversing their decision on Faselis. 

"After further consideration, 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," Veterans Affairs said in an updated press release.  

Eighteen of the medical center's 25 sterile storage areas were found to be dirty, according to the report by the VA Office of the Inspector General. In five storage areas, the clean equipment and supplies were mixed with the dirty. Seventeen areas lacked ways to monitor pressure, temperature and humidity.

The medical center lacked an effective inventory system, and $150 million in equipment and supplies were not inventoried in the past year. Meanwhile, the lease on a large warehouse of non-inventoried items expires at the end of the month with no plan to relocate the contents and staffing constraints could make it difficult to address the situation.

Also, no effective system was in place to ensure recalled supplies and equipment were not used on patients, according to the report.

The unsanitary conditions and lack of attention to safety recalls placed patients at risk, as did a failure to ensure availability of supplies and equipment when needed, the report said. For example, a nurse reported a floor was out of tubes used to provide oxygen when a patient was in need. On a couple of occasions in March, the Medical Center ran out of bloodlines for treating dialysis patients. 

In all, the medical center had 194 patient safety reports based on unavailable equipment or supplies since Jan. 1, 2014, according to the report.

"VA is conducting a swift and comprehensive review into these findings," the agency said in a statement. "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."

The Office of the Inspector General received a complaint about the conditions March 21, prompting inspections of the storage areas March 29-30 and April 4-6. A third inspection was planned for Wednesday.

The House Committee on Veterans' Affairs is conducting an active investigation into the facility, a spokeswoman said Thursday. 

"When our nation’s veterans go to a VA facility, they deserve to be treated with the highest quality care – not have their health and safety put at-risk due to a facility’s lack of oversight," Chairman Phil Rose, M.D. said in a statement. 

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