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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-02277-69
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified Sterile Processing Service (SPS)-related deficiencies as well as a continuation of previously identified deficiencies.

The OIG determined that SPS and operating room staff failed to remove nonconforming surgical instruments from a rectal tray that was used during a patient procedure. Moreover, the OIG found additional surgical instruments in nonconforming condition and that, contrary to policy, the reprocessing and use of nonconforming instruments was a permitted practice at the facility.

Additionally, facility leaders failed to establish a preventative maintenance program for the sharpening, repair, or replacement of surgical instruments prior to May 30, 2024.

The OIG also identified a continuation of previously identified deficiencies that included: the failure of facility leaders to fully implement an electronic surgical instrument tracking system known as CensiTrac, address concerns of the CensiTrac coordinator’s performance, and resolve concerns related to the intended use of an SPS conference and training room. Frequent changes in staff assigned to leadership positions, along with leaders’ failures identified above, likely contributed to the continued SPS deficiencies.

The OIG made two recommendations to the Facility Director related to ensuring staff’s compliance with identification and disposition of nonconforming surgical instruments and training operating room staff to recognize nonconforming surgical instruments. The OIG made three recommendations to the Veterans Integrated Service Network Director related to reviewing patients potentially affected by nonconforming instruments, evaluating whether administrative action is warranted for individuals regarding SPS deficiencies at the facility, and performing oversight of the facility’s implementation of facility-level action plans and sustainability of identified outcomes. 

Report Type
Inspection / Evaluation
Location

GA
United States

Number of Recommendations
5
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 5 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.

02 No $0 $0

The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.

03 No $0 $0

The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.

04 No $0 $0

The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.

05 No $0 $0

The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Centers Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.

Department of Veterans Affairs OIG

United States