March 7 (UPI) -- The results of a Veterans Administration investigation, released Wednesday, says failed leadership at multiple levels of the government agency put hospital patients at risk.
The 158-page report, "Critical Deficiencies at the Washington, D.C. VA Medical Center," follows a preliminary report on patient safety issued last year.
The VA Inspector General, the agency's watchdog, said at least three agencies directly under Shulkin's supervision were aware of "serious, persistent deficiencies," but did not indicate if Shulkin was aware of them. When he was appointed secretary, Shulkin said the problems were "systemic," and pledged changes and audits within the agency.
A February inspector general's report concluded a trip Shulkin took to Europe -- and a doctoring of emails to justify his attendance at taxpayer expense -- constituted an ethics violation.
The final report shows several cases of negligence and wasteful spending. It noted the Washington, D.C., medical center purchased speculums, a diagnostic tool, for $300 each when they could have been bought for $122 apiece. It also cites a $900 needle that was available for $250, and said the department once rented in-home hospital beds for three patients for three years at a cost of $877,000. The three beds, the investigation found, could be purchased for $21,000.
The D.C. medical also had over 375 patient safety incidents between 2014 and 2016 because of supply issues, which were not entered into a safety data base, the report said. The inspector general also cited an incident in which surgery was canceled after the patient was already under anesthesia, because a surgical retractor had not been sterilized after prior use.
Investigators also found over 500,000 unused items in an off-site warehouse, including $80,000 worth of refrigerators, $25,000 worth of blood pressure cuffs and 185 beds the hospital had acquired but which never entered service. Two forklifts purchased for $44,000 in 2013 were too large for warehouse use, so they remained parked, the report said. It also cited examples of confidential patient documents found in unsecured warehouses, the hospital basement and in a dumpster.