Sterile Processing Service Deficiencies and Leaders’ Response at the Carl Vinson VA Medical Center in Dublin, Georgia

The VA Office of Inspector General (OIG) substantiated allegations from January 2022 that employees did not properly reprocess reusable medical equipment (RME) within the facility’s Sterile Processing Service (SPS). Facility leaders halted all endoscope usage, as well as stopped surgeries and procedures requiring RME, until an investigation was completed. The OIG identified multiple issues that contributed to SPS deficiencies, including unaddressed, previously-identified issues within SPS, such as the failure to implement CensiTrac Instrument Tracking System, SPS standard operating procedures (SOPs) being out of date and not accessible to staff, competency training being inadequate and ineffective, failure to control traffic in the sterile area that potentially impacted the integrity of RME, and the negative impact of interim and acting leaders within SPS. In April 2022, the facility had potentially harmful, abnormal critical water test results, which led to another halting of all RME reprocessing. The OIG found that leaders delayed addressing consistently abnormal testing results within SPS. The OIG made two recommendations to the VISN Director related to reviewing the facility’s SPS water management program and ensuring the VISN SPS Management Board reviews critical water testing results. The OIG made seven recommendations to the Facility Director related to ensuring that the SPS chief conducts comprehensive staff competency assessments for reprocessing RME; the CensiTrac Instrument Tracking System is fully implemented and staff are trained in its use; SPS maintains a safe and clean environment in all areas where RME processing is performed; a plan is developed for remediation of the location of the training room adjacent to SPS’s clean storage area; all clinic areas have or share a designated soiled utility storage room; SOPs for all RME are developed and disseminated; and the facility Water Working Group submits critical water test results to the VISN.