New investigation reveals VA put veterans in 'imminent danger'

OIG: Patients put at risk at DC facility due to shortage, unsterile equipment


JACKSONVILLE, Fla. – An incriminating and concerning report from the Office of Inspector General that states VA put patients in "imminent danger" at the VA facility in Washington D.C.

The report, released Wednesday, reveals the Washington D.C. VA Medical Center put veterans at risk with expired medical supplies, a shortage of needed surgical equipment, lack of equipment to provide necessary aide to patients during a medical emergency -- even items used on patients that may not have been sterile. 

According to the report, hospital staff there is insufficiently equipped to perform operations, despite senior VA officials knowing about low inventory levels and unsterile conditions for months. 

OIG's investigation is still on-going but says it released its preliminary findings today based on the "exigent nature" of what inspectors had already discovered adding it found "a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk."


The report goes on to say OIG has a "lack of confidence in VHA [Veterans Health Administration] adequately and timely fixing the root causes of these issues."

It found in the past three years at this facility, there have been 194 reports that patient safety has been compromised because of insufficient equipment. These reports include surgeons using expired equipment during operations and biopsies being canceled because the right tools weren’t available.

While the preliminary investigation has not identified any adverse patient outcomes so far, here's a summary of what OIG did find:

  • 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. 
  • There are numerous and critical open senior staff positions that will make prompt remediation of these issues very challenging.

“It is completely unacceptable that veterans have been subjected to such dangerous conditions at the Washington DC VA," said Dan Caldwell, Policy Director for Concerned Veterans for America. "The VA did the right thing by relieving the DC director from his position, but he’s still being paid by taxpayers and under current law it will be very difficult to terminate him. Secretary Shulkin himself has said he wants Congress to pass legislation that will make it easier for him to quickly fire bad employees in situations like these. These systemic and reoccurring fire drills will not stop until the Senate moves on the strong accountability measures currently on the table.”


Following the release of the OIG report, the Department of Veterans Affairs says effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties, and it is conducting a "swift and comprehensive review" saying its top priority is to ensure no patient has been harmed.  VA says, if appropriate, additional disciplinary actions will be taken in accordance with the law.

As for the medical director's replacement, VA first named Dr. Charles Faselis -- saying it was following a common line of succession. But, after further consideration, the VA says it 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.

VA later announced Col. Lawrence Connell, US Army, has been named the Acting Medical Center Director for the D.C. VA Medical Center. Connell is currently serving as a Senior Advisor on policy matters focusing on development, adoption, and implementation of Department-wide programs and strategic issues.


You can read the preliminary OIG report on the VA facility in Washington D.C. here.