Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico

The VA Office of Inspector General (OIG) conducted an inspection at the Raymond G. Murphy VA Medical Center (facility) in Albuquerque, New Mexico, to assess allegations regarding deficiencies in the reprocessing and quality control of reusable medical devices (RMDs). The OIG also reviewed Veterans Integrated Service Network (VISN) 22 oversight of the facility Sterile Processing Service (SPS) leaders’ management of RMD reprocessing. The OIG substantiated that high-level disinfection (HLD) documentation was missing for endoscopes used in gastroenterology procedures for four patients. Three patients underwent procedures with anal manometers that lacked HLD documentation. In review of electronic health records, the OIG did not find adverse clinical outcomes for these seven patients. Patients were at risk for infection when RMDs used in patient care lacked HLD documentation. While the OIG could not determine if any RMDs were improperly cleaned prior to use, SPS leaders did not inform the Gastroenterology Service when HLD documentation was missing and precluded facility clinical staff from ensuring risks to patient safety were immediately addressed. Deficiencies in HLD quality assurance processes persisted into March 2023, despite facility leaders’ awareness of HLD findings from a May 2022 VISN audit. Specifically, SPS supervisors did not consistently complete daily quality assurance reviews of HLD documentation. The VISN failed to ensure facility leaders’ completion of action plans related to HLD findings from the VISN audit. The lack of VISN oversight resulted in delayed implementation of sustainable, corrective action, which did not occur for over a year from the original audit findings. The OIG made seven recommendations regarding VISN oversight of SPS audit findings, as well as facility identification, resolution, and quality assurance of HLD documentation and communication of SPS staff roles and responsibilities.