Department of Veterans Affairs officials mismanaged a Washington, D.C., medical center so badly over “many years” that providing safe care to veterans became a “challenge,” the agency’s inspector general wrote in a scathing report made public Wednesday.
The dysfunction spread from wasteful spending and shoddy record-keeping to unsterile surgical conditions that put patients at risk, according to the VA watchdog.
Dirty medical tools caused “avoidable hospitalizations” for some veterans and forced others to remain under anesthesia for “prolonged” periods of time while VA employees scrambled to find useable surgical supplies. Between January 2014 and September 2016, more than 300 “patient safety events” occurred due to problems with hospital supplies. VA employees broke agency rules by failing to report more than 100 of those safety breaches, the inspector general found.
The report comes amid scrutiny of VA Secretary David Shulkin’s spending on travel and an aide’s alleged efforts to conceal his conduct. Shulkin, an Obama administration holdover, was confirmed as undersecretary for health in July 2015 and oversaw the VA’s system of medical centers, including the mismanaged Washington hospital, in that role.
Shulkin announced plans on Wednesday to overhaul VA leadership in response to the report, including by naming new directors at more than a dozen VA hospitals around the country.
The inspector general noted investigators did not confirm any specific cases where a veteran died or suffered injuries due to the disorganization at the Washington VA medical facility. But the chaos put patients in danger, the watchdog found.
“[V]eterans were put at risk because important supplies and instruments were not consistently available in patient care areas,” the inspector general said.
Poor records management allowed VA employees to lose control of inventory and spend taxpayer money without proper scrutiny.
For example, leaders at the Washington hospital did not secure the resignation of a VA employee tasked with purchasing, who had charged thousands of dollars worth of “fraudulent” charges to his government-issued card, until four months after the scheme began.
“From July until September 2016, the purchasing agent bought eight Microsoft Surface Pro computers, eight iPhones, and two iPads for the same veteran,” the inspector general said.
The VA watchdog recommended 40 reforms the hospital could undertake to address its systemic failures.
“[A]t multiple levels of leadership, there were failures in accountability, responsibility, and oversight,” the inspector general said. “This lack of ownership and a pervasive practice of shifting blame to others contributed to a culture of complacency and neglect that placed both patients and assets of the federal government at risk.”
Shulkin said Wednesday during a press conference that employees at the Washington facility had already begun to make changes.
The VA secretary — once among President Trump’s favorite Cabinet members — has made accountability a focus since taking the top job at the agency last year.
Shulkin’s appointment by President Barack Obama came on the heels of the largest scandal in the VA’s history, when employees at dozens of VA hospitals around the country were caught falsifying patient waiting lists to cover up long delays veterans were facing when trying to seek care.
Trump made VA reform a focal point of his campaign, elevating the agency’s high-profile failures as evidence that the Obama administration was corrupt and inefficient. Since his unanimous confirmation last year, Shulkin has pursued reforms aggressively, including by seeking to fire more misbehaving VA employees than his predecessor under new accountability legislation.
