The inspector general for the agency said that William Jennings Bryan Dorn VA Medical Center did not adequately staff operating rooms or monitor patient care closely enough.
Dorn also has a “fragmented and inconsistent” infection control problem and rarely follows up to ensure problems are solved, according to the report issued Thursday.
Dorn officials did not immediately comment on the report Friday. But the inspector general’s release included memos by local and regional VA officials who acknowledged the problems and said some of them have already been remedied.
The new report comes months after another report linking six deaths to delayed screenings for colorectal cancer at Dorn, saying the hospital fell behind with its screenings because critical nursing positions went unfilled for months.
The new report doesn’t link the problems discussed directly to any deaths. But officials point out that Dorn was ranked almost at the bottom — 127 out of 128 — of VA hospital facilities in terms of health care-associated infections at one point last year.
The Inspector General investigation began after someone called a confidential hotline in November 2012 to complain about poor surgical care, policy violations, contaminated surgical trays — allegedly contributing to higher than average infection rates — and weak oversight and administrative control. VA officials visited Dorn a half-dozen times in 2013 to investigate and confirmed several issues, including improper use of log books, insufficient surgical clinic staffing and vacancies in anesthesia services.
Investigators also substantiated problems with scheduling surgical procedures, including operating rooms being closed in the afternoon — resulting in surgeries being canceled — to avoid having to pay overtime to employees. Some surgeries also were canceled the day they were scheduled to occur because of staffing shortages.
Officials also determined that Dorn has a “fragmented and inconsistent” infection control program and rarely analyzed information about transmission rates. Backup surgical instruments and materials, such as surgical mesh, weren’t always available because, according to logistics personnel at Dorn, “vendors had refused to restock supplies due to disputes over billing or payment.”
General surgery residents also weren’t adequately supervised, investigators wrote, after the three supervisory surgeons went on leave, resigned or quit. The residency program was put on hold but ultimately resumed, although the report noted that another lack of attending physicians means the program is again in jeopardy.
But officials also said some allegations were unsubstantiated, including claims that contaminated equipment contributed to surgical site infections and that surgical patients were harmed by a power outage. The report also said it could not confirm accusations that patients had been put under extensive anesthesia to give residents more training time in laparoscopic procedures.
The report made a dozen recommendations, including that Dorn adequately supervises, trains and evaluates employees. Blaming some of Dorn’s problems on a lack of consistency in leadership, the report also recommended the installation of permanent leadership and the use of electronic means to track and schedule surgical cases.
Dorn has 95 operating beds and 75 community center living beds. It serves about 410,000 veterans throughout South Carolina, according to the report. Last year, operating rooms at Dorn were closed after officials determined that problems in the ventilation system were causing dust to accumulate on equipment. Surgeries were farmed out to facilities across the Columbia area, and operating areas remain closed.