In light of a recent Office of Inspector General (OIG) report that cited exigent safety and patient welfare concerns at the Washington D.C. VA Medical Center, The American Legion Washington Office held a crisis town hall meeting May 3 to hear feedback from local veterans about their quality of health care and overall VA experience.
Over 100 people attended the town hall which was held inside the medical center’s auditorium. Representatives from the Legion’s National Headquarters Washington Office, American Legion Department of D.C., the U.S. Department of Veterans Affairs Central Office as well as the District’s congressional delegation were among the attendees.
“The D.C. VA Medical Center has entered into a crisis mode,” American Legion National Veterans Affairs and Rehabilitation Director Louis Celli said as he gave opening remarks. “There’s been an (OIG) report that has revealed some things that patients may or may not even know about. The reason that we’ve asked you to come here tonight is twofold. One, we want to hear from veterans about what your experiences are here at the VA medical center, and we also want to see if your experiences (reflect what was found) in the report.”
Last month, the Legion learned that the medical center director was relieved from his position following an Interim Summary Report released on April 12 by Inspector General Michael Missal. The report “preliminarily identified a number of serious and troubling deficiencies that placed patients at unnecessary risk.”
Although the OIG has not yet identified any adverse patient outcomes, Missal said 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 had a lease expiring on April 30, 2017, with no effective plan to move the content 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.”
“My top priority is the safety and well-being of the veterans we are privileged to serve,” D.C. VA Medical Center Acting Director Lawrence “Larry” Connell said in an email the Legion received on May 4. “I do, however, want the information we share to be accurate and clear, and this sometimes takes time.”
According to the report, “the medical center placed patients at unnecessary risk by failing to ensure that:
appropriate medical supplies and equipment were available to providers when needed;
recalled supplies or equipment were not used on patients; and
sterile supplies were stored appropriately.”
At the time of the OIG’s site visit, “the medical center was in the process of conducting a patient safety review because sterile processing ran out of supplies to test the insulation of scopes used in laparoscopic or endoscopic procedures. … If this occurs, patients may develop burns or latent infections,” Missal noted in the report.
“The medical center could not verify whether this testing had been done on scopes used in approximately 20 procedures since February 28, 2017 (to) March 16, 2017,” Missal said. “The OIG further determined that supply issues had persisted for some time … in which patient care was compromised as a result of the failure to maintain appropriate equipment or supplies within the medical center.”
In addition, Missal noted that “at least some of the issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation.”
“No patients have been harmed according to the information that we have to date,” Connell said during the town hall event. “Though we still have to complete our internal review, neither the inspector general nor the VA have identified any cases of patients who were harmed due to the issues at this facility. … To ensure patient safety, the D.C. VA Medical Center promptly addressed supply and equipment insufficiencies throughout the facility and implemented a robust oversight process that identifies and addresses new supply or equipment shortages.”
According to the OIG’s report, one situation in which patient care was compromised was in June 2016, wherein “the medical center discovered that one of its surgeons used expired surgical equipment on a patient during a surgical procedure. The medical center determined that the lack of an inventory management program caused the error.”
Missal went on to say that, “rather than undertake measures to implement an appropriate inventory program, the medical center elected to require its nursing staff to conduct monthly rounds to identify and remove any expired supplies.”
Veteran Terry Duncan shared his bad VA experience following a surgical procedure he needed on his knee due to an accident in 2010. “I came here for surgery on a Saturday night at about 11:00,” he said. “I’m diabetic. … From 11:00 in the evening, I had nothing to eat, until 9:00 Sunday morning, I was released. They said (I) had to come back for a (consultation) with the orthopedics. … They slapped a cast on my leg that Sunday morning (and) sent me home with some pain killers. … I got a call Monday night and they said they had (scheduled me for surgery) on Tuesday. I came in Tuesday (and then) Wednesday morning, they did the surgery.
“At the time before I was released,” Duncan continued, “I was experiencing shortness of breath when I just got out of the bed trying to walk to the bathroom with a crutch. My pulse rate was high – all of this was being monitored by professionals in this clinic. I did not know at the time that those were the signs of blood clots. I had blood clots in my lungs. I was released on that Friday, went home, passed out on the floor, (regained consciousness) and came back to the hospital that morning and found out I had a 50 percent chance of making it. This was after surgery. Any other hospital in the country (that does) orthopedic surgery on your knee, everyone I spoke to (said you’re supposed to get) blood thinners. In addition to not getting blood thinners, I was not given anything for infections. I had (severe) infections when I came back here and had to take blood thinners … for six months to a year. … I’m permanently crippled because of the incompetence and maleficence of the surgeon that was (practicing) here. And no one has done anything about it.”
As recently as of March 15, Missal noted in the report that, “the medical center ran out of bloodlines for dialysis patients on the second shift – they were able to provide dialysis services to those patients only because staff borrowed bloodlines from a private hospital.”
Concerned veteran Arthur Goff said he is appalled with the diabetes clinic. “I walk through the facilities and one of the things I’m concerned about (is that there are no) good facilities here for diabetics,” he said. “We used to have an office for diabetics (but) now, we got to use other space and space is so limited here.”
Dr. Charles Faselis, the medical center’s chief of staff, responded to Goff’s concern. Faselis said a new diabetic center is currently in the works and will be located on the fourth floor.
“We have to have diabetes care in one area,” said Faselis. “I assure you that everybody, all the clinicians are aware of that. We know that it was a mistake. … We feel that when everybody is in the same place, you get better care. … Give us a chance and I think you’re going to see something happen over the next couple of months.”
Furthermore, “OIG staff inspected 25 sterile satellite storage areas and identified numerous ongoing deficiencies. Specifically, OIG found that:
Eighteen sterile storage areas were dirty.
Five sterile storage areas mixed clean with dirty equipment or supplies.
Eight sterile storage areas contained supply racks lacking solid bottom shelves as required to reduce cross-contamination from the floor.
Seventeen sterile storage areas lacked a method to monitor pressure, temperature and humidity.
Five sterile storage areas were cluttered.
Five sterile storage areas improperly served multiple purposes including office and patient care space. These areas also lacked security and appropriate environmental controls.”
Under such conditions, Missal said the medical center “lacks assurance that sterile supplies maintained their integrity. … Moreover, the medical center’s failure to maintain an adequate inventory management system is placing a significant amount of assets of the federal government at unnecessary risk. Accountability over supplies and equipment is not adequate.”
Army veteran Russell Stott voiced his frustrations about a lack of hospitality, long wait times and poor quality of care. Stott said he’s been writing complaint letters about the D.C. facility since 2009. “The problems here are systemic,” he said. “You have a culture that has to be changed. ... I walk in this facility every time with a new attitude. But the problem is I walk out frustrated every time.”
Another situation that placed patients at unnecessary risk came on March 29. According to the OIG’s report, “a vendor loaned bone cements to cover two total knee replacements for surgeries scheduled that week. Operating room staff requested that prosthetics purchase the bone cement, but was told the company could not deliver it until the next week.”
“The prosthetics clinic needs an overhaul,” an unidentified Operation Enduring Freedom (OEF) woman veteran said. “Every time that I try to come in for a prosthetics (fitting), they’re either out of something or they don’t have it. It’s not just me, but other veterans have also had to wait weeks and months to receive our prosthetics.”
For other veterans like James Preston who served in the Vietnam War, he credits the D.C. VA hospital for helping him survive three bouts of cancer, including a lung removal.
“It was this center that took care of me,” Preston said. “I left out of here not having to have any (chemotherapy), radiation or anything. … I’m just happy to be alive.”
Fellow veteran Kerby Stracco also had some positive things to say about her VA experience. “The polytrauma team is exceptional,” said the mom of three who suffers from a mental illness. “They call, they check on me if I miss my appointment. The doctors, not the secretary, will keep calling me. … They really help out so I really appreciate that.”
Connell said he is a big proponent of total transparency and having open conversations about how the medical center can be better for veterans. His focus over the coming weeks will be on assessing the facility’s environment of care.
“I will spend this time listening to veterans, employees, Veteran Service Organizations, members of Congress and our community partners. Their insights will be invaluable and will help chart our path moving forward,” said Connell. “As a veteran, I strive to embody the values central to the Department of Veterans Affairs every day, and I will bring that same level of care and commitment to the veterans community in our nation’s capital.”
As the nation’s largest and most influential VSO, The American Legion is devoted to mutual helpfulness.
“We’re all here because we care,” said Verna Jones, executive director of the Legion’s national office in D.C. “Mr. Connell, we’re here to help you and The American Legion stands behind you. We’re happy that you’re here and that you have such a passion for veterans and that you put your leadership team together to make sure these heroes get exactly what they deserve. It’s only going to get better from here.”