Issues persist at Dublin Vets hospital that exposed patients to infection, officials say
A Middle Georgia Department of Veterans’ Affairs facility is under fire by federal officials for allegedly failing to address concerns around tool sterilization and patient safety, even after two federal investigations.
A Tuesday letter from Sen. Jon Ossoff (D-Georgia) to Dr. David Walker — a Veterans Integrated Services network director whose jurisdiction includes the Carl Vinson VA Medical Center — alleges that the hospital improperly sanitized re-usable medical tools including an endoscope and rectal tray in multiple incidents between 2022 and 2024.
The letter also alleges that facility leadership has not done enough to address issues, and asks that they outline steps to improve.
The first incident occurred in January 2022 when a staff member allegedly placed a used endoscope that had not been reprocessed into storage with sterilized tools, according to a March 2024 report on the hospital released by the VA Office of the Inspector General. An endoscope is a flexible tube with a light and camera used by medical professionals to examine organs.
Hospital staff reported the endoscope issue that morning, and a second report of issues with sanitation and endoscopes was reported at the end of the day, the inspector general’s office said. The facility halted all endoscope activities, and then “elected to curtail all surgeries and procedures requiring the use of reusable medical equipment until a thorough investigation could be completed.”
The report said investigators could not be certain of the extent of the sanitation issues, but notified about 6,600 patients who may have been impacted by the use of unprocessed instruments.
“(The facility) could not tell with 100 percent certainty that the endoscopic processes were being conducted correctly across fields,” the report said. “Due to endoscopes being complex and delicate instruments with various holes and ports, thorough and orderly sterilization through many steps is required to ensure the elimination of contaminants.”
Issues carried on into April 2022, when water being used during procedures was found to be “harmful” and “abnormal” during a water test, the report said, resulting in more operations being suspended.
The letter and report also allege that leadership at the facility failed to remedy concerns about safety and sanitation after the 2022 incident.
According to the 2024 report, hospital leadership did not provide adequate training to staff members and failed to manage areas and processes where instruments and equipment are sanitized. The report detailed instances of staff members allegedly eating, drinking and even storing food in sterile areas where clean tools are kept.
Additionally, while the report says facility leadership responded to the incident involving the endoscope, the inspector general’s office said that leadership “enabled a culture of complacency and unaccountability” by not addressing deficient conditions and concerns related to patient safety.
However, even after the investigation, trouble at the hospital remained.
Just after the report was published in March, a routine inspection allegedly found a rectal tray — a tray of tools used by medical professionals during rectal examinations and procedures — that included instruments that were “pitted, stained and tarnished” and “not suitable for service,” according to a report on the issues published in March of this year.
An investigation into the incident by the inspector general found at least 800 instruments that were not suitable for use, the March 2024 report alleges, which potentially placed thousands more patients at risk of contracting infections. The instruments were regularly being used for surgeries, examinations and procedures, the letter and reports said.
The more recent report alleges that facility leaders failed to implement a preventative maintenance program for tools to keep them in good condition, and often overlooked the use of unsuitable instruments.
“Their investigation also revealed a clear continuation of previously identified sterile processing deficiencies that reflected failures at all levels of leadership within the department, facility, and VISN,” Ossoff said in his letter to Walker.
The inspector general’s office made nine recommendations in the 2024 report. Seven were directed at the facility director and two were directed at the VISN director. According to Ossoff’s letter, one facility recommendation remained open as of Sept. 1, meaning that recommendation had not yet been implemented by the facility. The second report made another five recommendations, which are all currently open.
Ossoff’s letter has asked facility leaders to outline the steps they have taken to implement the unaddressed recommendations. The letter also demands higher standards for sanitizing and organizing equipment.
“It is unacceptable to allow veterans to remain at risk and immediate action needs to be undertaken,” Sen. Ossoff wrote.
Neither the Carl Vinson VA Medical Center nor Walker responded to requests for comment prior to publication.
This is a developing story and may be updated.