Storage areas for medical supplies were filthy. Nobody knew what was in the storage areas anyway. Medical supply rejects could have been used on patients. More than $150 million in supplies and equipment had never been inventoried.
And management was clueless about all this.
In a scathing report, the Inspector General for the Department of Veterans Affairs listed a range of overlooked and long-standing problems at the Washington, D.C., VA Medical Center "sufficient to potentially compromise patient safety."
The risk to the 98,000 vets served by medical center in the nation's capital was so high that the office of Inspector General Michael Missal took the unusual step of issuing a preliminary report to alert new VA Secretary Dr. David Shulkin to the danger.
"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 [Veterans Health Administration] adequately and timely fixing the root causes of these issues," Missal said in the report.
The last time the IG's office issued a preliminary report was January 2015, involving urology care that was endangering patients at the Phoenix VA medical facility, scene of a well-documented wait-times scandal.
The report singled out management at VHA for the risk to patients at the Washington VA Medical Center. "At least some of these issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation," the report said.
Although the IG's office stressed that it has yet to find any "adverse patient outcomes" in its ongoing investigation, preliminary findings include:
-- No effective inventory system for managing the availability of medical equipment and supplies used for patient care.
-- No effective system to ensure that supplies and equipment that were subject to patient safety recalls were not used on patients.
-- Eighteen of the 25 sterile satellite storage areas for supplies were dirty.
-- More than $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.
-- Numerous and critical open senior staff positions have been left open and will make prompt remediation of these issues very challenging.
Management was clueless on the issues potentially affecting patient care at the medical center, the report said. The IG's office began looking into the problems based on a whistleblower's complaint describing equipment and supply issues.
The shoddy oversight of the medical supply system led to shortages in operating rooms, the report said. 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.
In addition, the hospital had to borrow bone material for knee replacement surgeries and also ran out of tubes needed for kidney dialysis, forcing staff to go to a private-sector hospital to procure them, the report said.
In response to the IG's report, the VA issued a statement saying that the director of the medical center director, Brian Hawkins, had been relieved and placed on administrative duty "effective immediately."
"The department considers this an urgent patient-safety issue," the statement said. "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."
The VA initially named Dr. Charles Faselis, who was part of the existing management at the Washington VA Medical Center, to serve as acting director but reversed that decision on Thursday.
In a statement, the VA said that retired Army Col. Lawrence Connell, now a senior adviser on policy at the VA, would serve as acting director of the hospital.
"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," the VA said.
In his 30-year military career, Connell served as an Army medical service officer, including 15 years as a MEDEVAC pilot as well as chief operating officer of Pacific Regional Medical Command in Honolulu, the VA said.
The IG's report posed an immediate challenge to Shulkin, who has won praise from President Donald Trump and veterans service organizations for his pledges to improve accountability for management at the VA. Shulkin also won thousands of exemptions for the VA from Trump's 90-day federal hiring freeze and a pledge of a major boost for the VA's budget.
However, the IG's report on the Washington VA Medical Center could put Shulkin on the spot.
"The details documented in this report regarding serious patient safety issues at the Washington, DC VA are outrageous and unacceptable," said Rep. Tim Walz, a Minnesota Democrat and the ranking member of the House Veterans Affairs Committee. "When you have systemic failure on this level, management must be held accountable."
-- Richard Sisk can be reached at Richard.Sisk@Military.com.