VA Medical Center

What One Watchdog Group Found At One VA Medical Center Will Shock You (Maybe)

VA Medical Center

The results of one watchdog inspection of a VA medical center days ago shocked VA leadership into removing the director from the facility immediately.

The new Secretary of Veterans Affairs unveiled some new policies and software tools this week that have advocates taking a step back including removing a VA director.

The watchdog group was VA OIG. They found that the director’s facility put veterans’ lives in danger, recalled medical supplies were likely used on veterans, missing supplies and tools forced veterans to go without lifesaving procedures, and dirty supplies were mixed with sterile supplies.

All of these acts could put many veterans’ lives at risk.

Despite IG’s finding that no evidence exists as of yet to show any veterans were harmed, the number of infractions were so numerous that it shows the director clearly lacked common sense and care for the lives and health of veterans.

Imagine How Your Boss Would React

Imagine this scenario.

For over two years, VA worked with government contractors to increase the appearance of transparency with a website. That website would show the wait times at all VA facilities but falls short by not revealing raw data for public scrutiny.

RELATED: VA Releases Wait Time And Quality Transparency Tool

Nonetheless, the fanfare surrounding the move makes VA shine in the press.

Imagine that same day VA OIG releases a scathing review that the VA medical center located in the Washington DC, right under the noses of VA Central Office, was putting veterans’ lives at risk.

It really takes the air out of an otherwise positive press day for VA. I can only imagine how pissed Secretary Shulkin was to learn his VA ruined the big reveal.

Not taking the news lying down, Secretary Shulkin immediately demoted the respective director responsible for the facility and replaced him with an outsider.

Even folks like Brandon Coleman, a well-known VA whistleblower, was impressed with the swift reaction. He sent me a text immediately after the report came out.

Normally, VA has normally been known to sit on its laurels while an embattled director took retaliatory measures against any VA employee responsible for telling OIG the information leading up to the scandal.

Not here.

In a first for this administration, however, Secretary Shulkin revealed he is willing to immediately remove and replace any director linked to endangering the lives of veterans.

“The Department of Veterans Affairs thanks the OIG for its quick work reviewing the D.C. VAMC,” the VA said in a statement. “The department considers this an urgent patient-safety issue. Effective immediately, the medical center director has been relieved from his position and temporarily assigned to administrative duties.”

VA removed Brian Hawkins and placed him on administrative duties pending the result of the investigation. Hawkins was first appointed as the director in 2011 and obviously had ample opportunities to fix any existing problems.

“VA is conducting a swift and comprehensive review into these findings,” the statement continued. “VA’s top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law.”

Why would Shulkin move to remove Hawkins so quickly?

Here is a bullet list of what different infractions IG found and admitted within its interim report.

IG Report Summary Problems

In summary, the facility:

  • Failed to keep a normal supply of required supplies and equipment to perform the lifesaving services expected of all major VA medical centers
  • Failed to use proper protocol to remove recalled supplies and equipment to not put veterans’ lives at risk.
  • Failed to ensure supplies were sterile but instead using dirty supplies.

Washington DC VA Medical Center Missing Supplies And Equipment

Here are the full bullet points on missing supplies and equipment:

  • At the time of our site visit, the Medical Center was in the process of conducting a patient safety review because sterile processing ran out of supplies to test the insulation of scopes used in laparoscopic or endoscopic procedures. This testing is used to detect holes in the insulation surrounding the scopes that may result in the transmission of electrical current into surrounding tissues. If this occurs, patients may develop burns or latent infections. The Medical Center could not verify whether this testing had been done on scopes used in approximately 20 procedures since February 28, 2017-March 16, 2017.
  • As recently as March 15, 2017, the Medical Center ran out of bloodlines for dialysis patients on the second shift—they were able to provide dialysis services to those patients only because staff borrowed bloodlines from a private hospital.
  • On March 29, 2017 a nurse emailed the patient safety manager, reporting that during an acute episode, she needed to provide oxygen to a patient. The floor was out of oxygen nasal cannulas (tubing that fits into a patient’s nose and provides oxygen). The nurse was able to use one found on the crash cart, but reported the shortage as a risk to patient safety.
  • On March 29, 2017 a vendor loaned bone cements to cover two total knee replacements for surgeries scheduled that week. Operating room staff requested that prosthetics purchase the bone cement, but was told the company could not deliver it until the next week.
  • On March 30, 2017 the dialysis unit ran out of dialyzer bloodlines and 15 gauge fistula needles, both of which are essential for dialysis treatments.
  • On April 4, 2017 staff inspected the storeroom on the floor that had run out of the oxygen nasal cannulas. Between 11 a.m. and noon, OIG staff determined the storeroom was out of alcohol pads; slipper socks/aqua shoes; denture cups (plastic containers used to store patients’ dentures); and large tegaderms, a type of wound dressing. OIG was informed that nursing staff inventoried the rooms three times a day, and sent requests to logistics to replenish stock as needed. However, when OIG staff returned after 6 p.m. on the same day, only the alcohol pads had been replenished.
  • On April 5, 2017 the lead sterile processing technician had been tasked with finding a clip applier for use in a procedure scheduled to occur the next day. A clip applier is a device that deploys surgical clips that may be used to close off blood vessels or other tubular structures. OIG staff accompanied the technician as she searched for the device in the sterile processing department and in the central supply room. Despite having the purchase order number for the device, she was unable to find it.
  • On April 11, 2017 received an email stating that the operating room (OR) ran out of vascular patches, despite having requested the assistance of the Deputy Chief Medical Officer of VISN 5 in obtaining them two weeks ago. The OR also ran out of Doppler probes. Nursing staff stated that the ORs could not form emergent or elective open vascular surgery without those in stock.
  • On April 11, 2017 received an email stating that the OR ran out of sequential compression devices (SCDs). These are devices placed on patients’ legs to prevent blood clots during surgery. Surgery proceeded without the devices.

Longterm Supply Problem

VA OIG later determined the above problems existed for some time:

  • Since January 1, 2014, the Medical Center has recorded 194 patient safety reports relating to the unavailability of equipment or supplies.
  • In February 2016, a Stryker bone tray used in surgeries to repair mandibular (jaw) fractures had been removed from the facility due to outstanding invoices from the vendor. Surgical staff informed us that a procedure had to be delayed as a result.
  • Four prostate biopsy surgical procedures were canceled on April 25, 2016 because prostate biopsy guns were out of stock. A nurse wrote an email to the medical center director on April 26, 2016 recommending an OR “stand down” until the operating room’s inventory situation could be remedied.
  • In June 2016, the Medical Center discovered that one of its surgeons used expired surgical equipment on a patient during a surgical procedure. The Medical Center determined that the lack of an inventory management program caused the error. Rather than undertake measures to implement an appropriate inventory program, the Medical Center elected to require its nursing staff to conduct monthly rounds to identify and remove any expired supplies.
  • On March 16, 2017, the facility found Sterrad chemical indicator strips that expired on February 28, 2017 in sterile processing. The indicators are placed with equipment and change colors when exposed to hydrogen peroxide. This allows a visual verification that sterilization occurred. The Medical Center could not determine whether the expired indicators had been used on some of the 396 items sterilized in the Medical Center between the date of the strips’ expiration and the date staff discovered the expired strips and removed them from the facility.

Washington DC VA Medical Center Dirty Supplies

IG also found VA was mixing clean supplies with dirty supplies:

  • Eighteen sterile storage areas were dirty.
  • Five sterile storage areas mixed clean with dirty equipment or supplies.
  • Eight sterile storage areas contained supply racks lacking solid bottom shelves as required to reduce cross-contamination from the floor.
  • Seventeen sterile storage areas lacked a method to monitor pressure, temperature, and humidity.
  • Five sterile storage areas were cluttered.
  • Five sterile storage areas improperly served multiple purposes including office and patient care space. These areas also lacked security and appropriate environmental controls.

It is surprising such a scandal existed right under the nose of senior leadership with VA. Or is it? Where you shocked or not?

I cannot help but wonder if VA leadership allowed these problems to fester right under their noses and could not detect the stench for years, how much is going on nationwide?

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  1. Who pays for the fix? We know veterans will. Compensation for those collecting SS will be cut out! Ryan has wanted this for years, but didn’t have anyone to sign law. New Sec. Backs this. He’s told VVA this. They call disability , unemployment! ‘Why are paying 80 year olds unemployment’ new VA Sec. stated. I don’t know but I enlisted in 2966 and it was promised health care for life! After all voluntary started did laws change?
    Call your house and senate representatives

  2. PS: I always told my vets, if you have a legitimate claim, don’t let them frustrate you to the point where you say “fuck it” and stop pursuit because you don’t want to deal anymore with the pricks… I had one patient who finally won a claim after about 20 years…. the process is geared to get you to drop out… don’t do it. I unfortunately have not followed my own advice.. I couldn’t stick with it. I broke my back while in the service, was a para out of surgery, was on a circle bed for 4 months, and after a year of rehab recovered to the point where I was able to compensate for my spinal cord injury. I developed more problems, was evaluated and received a finding that there was nothing wrong with my back… I said “fuck it” and didn’t want to deal with the frustration and psychological toll of continuing to fight. I couldn’t follow my own advice. Don’t let them win… stick with it. If your claim is legit, you will eventually win. God bless you and America too.

    1. It’s all Bushes fault.. I have news for you, the VA has been screwed up long before Bush came along. You’ll not be fooling anyone around here. We all know better. I have been receiving bogus care since 82′. Wanna try again?

    2. The Secretary must take no Poisoner’s, Collaborator’s are just as Guilty as the Offender ! That message must be given to all VA Employee’s and if caught out the door you go.

      Claims that have been denied wrongly, that employee and the Manager need to be held Accountable, three strikes and your out and good riddance or charges filed for falsifying Data.

      Veterans Must write the Secretary and tell him their stories, with Names, places, time, old and new !

      Stand up, its your turn to be Heard !

  3. I remain amazed at the constant barrage of insults thrown at the VA. IMHO, the VA as an institution has many problems but so many of the criticisms are misdirected. Maybe my view is skewed, but my experiences have at times caused frustration but I have never received improper care… the usual frustration was due to the sloth slowness of getting care that I deemed needed. It is not the fault of the provider in most cases. One needs to understand that the provider has forcibly become nothing more than someone who must fill out a check list of required to do’s that leaves little time for interaction as a healthcare provider taking care of a patient. These requirements are dictated by non-providers who sit in committees and justify their jobs by spitting out policies. The provider, the one who is ultimately responsible for taking care of the vet has become a list checker. As a former employee, a provider, and a vet, I saw this transformation occur over a period of time starting under Bush II. There was an explosion of mid-level administrator hires who did little more than to hamper the care provided to the vet. If the VA were a sail boat, it would tip over it’s so top heavy. My last interaction as a patient was one of frustration; I’d developed a cervical radiculopathy and needed a MRI to document the cause. Believe it or not, my provider was not able to order the MRI due to policy. She first had to do Cervical spine films which showed what we both knew it would show; she then had to send me for an EMG.. a test that has only a 33% accuracy rate(which btw is used to deny many claims); I then had to be referred to a specialty who then was able to order the MRI which showed what was clinically evident. I then was referred out via the new program instead of using the fee basis program that has existed internally for years; this took a few months; by the time I was finally scheduled about 6 months had passed. Now most would say how terrible the care at the va is. A decade or so this process would not have happened; I would’ve seen my provider who would’ve made a dx based on textbook clinical findings; an MRI would’ve been ordered and I would’ve been seen in house within 30 days and treated. What I am getting at is most of the problems we experience is not because of the providers. There are always bad apples, but most of the people who actually take care of the veteran are competent, their licenses are up to date… this is vigorously monitored and enforced, and actually are committed to providing quality care to the vet. IMHO, the problem is that these providers are slowly burning out not because of the veteran but because of all the administrative BS that must be done instead of just being able to do what they were trained to do… be health care providers. They have been forced especially on the primary care level to be nothing more than gate keepers. If you want to improve the va two things need to be done: #1 get rid of the bonus system. This leads to corruption and the people who actually interact with the veteran are not the ones receiving the bonuses; and besides, why should you get a bonus for doing what you are hired to do; #2: decrease administrative staff, especially “supervisors by 75 to 80% and put the physician back in charge of taking care of patients. For every horror story in the va, there are 10 fold in the private sector. And, remember, the disability wing and the healthcare wing are totally separated; don’t lump them together. You can only provide quality care if you have the providers and the resources to do that. The VA opened up to all veterans without have the facilities and the providers to care for this tremendous influx of patients. As far as I know, no one was charged with embezzlement when all the thievery was revealed with the bonus program.. many should have gone to jail. Instead, the program continues. If these people had worked for a business and kept two sets of books and were caught taking money not rightfully theirs, they would’ve faced charges. Not so in the VA. Purge the administrative staff, channel that money towards direct care… that is what will benefit the veteran.

    1. There lies the problem. Leadership or lack of. You have managers who through the buddy system have undermined the system. They are not qualified and ignore the regulation as intended or simply do as they please.

      Now providers have two choices, do it right or do it the VA way. Wing it.

      Its fumy everything is ok, until someone has to deal with them as a veteran. That’s why veterans say that our elected officials should be forced to use the VA for treatment. Then and only then will they understand the veterans plight.

      ? as a provider, what constitutes disruptive behavior. Don’t look it up. just give us your take on the subject.

    2. Lindsey, although parts of your comment come across as talking down to us veterans and condescending, an attitude we have come to love so much, you make other good points, so I will give you the benefit of the doubt.

      You complain about the barrage of insults directed at the VA, but you will never hear them from the vets killed by the VA or their surviving family members. The insults are well deserved until the VA starts policing their own. Allowing bad providers to continue hurting veterans will continue to get called out, particularly when those “bad apples” are known bad apples to the VA, and their malpractice results in maiming or death.
      No. Complaints are not misdirected, for exactly the reasons I spelled out above.
      Until providers start policing their own, even the good providers are going to catch flak..

      What’s worse? The feelings of a good provider? Or another family wondering why their loved one is dead because a bad Apple was tolerated?
      You may have seen the news, but Trump just signed an Executive Order creating an office to protect whistle blowers. If your feelings are hurt by being lumped in with bad apples, then blow the whistle and report the malpractice, corruption and fraud that you see.
      You mention your wait for health care and claim it is not that bad.

      6 months is a lifetime to a veteran dealing with debilitating pain and not being able to leave their house. 6 months is a lifetime to a veteran with severe PTSD and possibly suicidal.

      6 months has been a death sentence to many veterans with cancer being ignored by the VA.

      I agree getting rid of bonuses and administrators would be a start, but it would only be a start. Bad administrators would find a way to scam the system even if their bonus was eliminated. Rubens and Graves showed us that.

      You want to fix the VA, start by having every licensed provider be licensed in the state they practice in, and subject to the same jurisdiction and licensing requirements as private providers. If VA providers are as stellar as you claim, there should be no problem with this.
      I see a problem though. At my own small VA, at least 10 providers have infractions against their license, several have more than one, at least 6 have been sued for malpractice, at least 3 sued more than once, and 1 in particular was given a $3000 bonus even though he had been sued twice.

      Don’t blow smoke up my ass about VA provider licensing when states regulate a hair stylist or plumber more closely than a VA doctor because the VA likes to claim federal jurisdiction.
      In addition to that improvement, require under federal prosecution that any VA provider follow any guidance or laws requiring Informed Consent for medical research. Stop using veterans as uninformed guinea pigs.

      Stop violating the civil and human rights of veterans using the fascist Disruptive Behavior Committees.

      Make it illegal for any VA provider to profit from medical research performed on veterans. Dr. Shinazi and his multi billion dollar Hep C drug comes to mind.

      Prosecute and imprison those who perform unauthorized research on veterans. Without that, some VA providers are little more than unpunished Nazis.

      You say problems are 10 fold worse in the private sector. I call bullshit on that.
      Those in the private sector that commit malpractice, maiming or killing of patients often do not last long. Why? Because there are state mechanisms in place for those harmed to weed out those bad apples. They can also be sued easily, and I truly believe license requirements such as ongoing training and certifications are much tighter.

      In the VA that bad Apple never gets pulled. They get shuffled to another VA, or promoted into administration.

      You say the disability and health care sections are two distinct sections in the VA, and should not be lumped together. I believe that shows incredible ignorance for someone claiming to be a veteran and VA provider, because it shows a lack of understanding of one (healthcare) being very dependent on the other (disability rating).
      Without a disability rating indicating a medical condition is service connected, a veteran is very unlikely to see any health care for that condition, unless they are below a certain income level.

      Which leads to another improvement you left out. Stop allowing providers to practice outside their specialties.

      You would not take your car to a plumber to have your oil changed, so why does the VA allow unqualified providers to practice outside their specialty?

      The VA likes to use General Practioners for C&P exams for things like brain injury and skeletal problems, or for nervous or gastrointestinal systems. All this does is result in fraud against the veteran, a denial of service connection, which leads to a denial of health care.

      Until these improvements happen, you should expect to continue to have hurt feelings.

      1. Your reply was outstanding some VA employees just can’t see through their rose colored glasses.

        You said it in a very non disruptive manner !

        Sometimes the truth really hurts. Good, now the shoe is on the other foot.

        I hope we from a lot of other VA employees crying foul. It wasn’t me ! I was framed !

        All I can say is bye ? !

        Nice job !

  4. im wondering when dr linda bortguno and dr ricardo pena will be investagated and brought up on charges for attempted murder.

  5. your right not surprised. Its still the norm. Cant fire him, have to shuffle them around. Administrative duties.

    Administrative duties, that is what he was doing in the first place and did a bad job. I don’t understand why the new law has not passed to fire bad employee’s.

    Up to 2 years it takes to remove an employee. We have heard over and over about how the VA is messing up and how many employee’s don’t seem to understand that their jobs could be on the line and continue to treat veterans as less that second class citizens.

    I guess many think or don’t think that one day soon, the bill will become law. Everyone needs to call their senators office and express that the law is needed and to pass it ASAP. Veterans are dying, VA is Lying.

    Lets change that to Veterans are living, VA employee’s are being fired.

  6. I got a big favor to ask you all. My husband has been misdiagnosed, which we just recently found out. He has a tumor, that VA said was not growing , not malignant, wouldn’t cause him any problems.
    Well they were very wrong. sais tumor has taken his eyesight, causing extreme headaches. They have scheduled another MRI thinking it is due to pressure on his brain. That is how we figured out w had been lied to. Just told it is inoperable. I am scared to death!! A friend that works at another VA facility, told us to get a lawyer. We live in Texas. Does anyone know of an attorney ? Please help me help him . We’ve been married 35 yrs & I don’ want to lose him. There isn’t any amount of dollars that would replace what he has lost. Any help would be so greatly appreciated!! I think I am gonna lode my mind, seriously.
    Thank you all for your time & listening. I got no where to turn.

    1. @Debra, you could e-mail Ben Krause and ask for a referral for an attorney in your area. You can google for a Veterans rights attorney. I would keep trying to contact people and ask questions and ask for help from whomever you can. Keep trying. Best wishes and God Bless you and your dear husband.

    2. @Debra Stringfellow: Debra, look here I hope this can help.

      Texas lawyers for Texas Veterans. “” They provide pro bono work for Texas Veterans.

      Also “” The Texas Veterans Legal Assistance Project.

      “” Lone Star Lawyers for Lone Star Veterans, Lone Star Legal Aid

      Texas civil rights project veteraans services “”

      American Bar Association “” pro bono rescorces for veterans.

      God Bless you and your family.

  7. SameO, SameO…Nothing has changed and the VA track record indicates that nothing will change. If we look at all of the reports of similar incidents over the last 5, 10 years, all that has changed, is the name of the facility and geographic location. The reason why this debacle is continuing, is because, no one, who has the power to bring about change, has stepped forward and said, “Enough Is Enough!”. The Veterans Administration Secretary, is appointed by the President. The House and Senate Committees For Veterans Affairs has oversight and can convene hearings. We the Veterans, do not have a single voice Advocate. Emails to the VA Secretary are going unanswered. The President has not responded to any Emails that have been sent to the White House Veterans Hot Line. Meanwhile, the VA continues to do whatever it wants to do, without any fear of reprisal. Forget accountability. President Trump, has at his disposal, the finest minds, that are experts at managing businesses and Health Care experts that know how to run mutiple Heath Care Facilities. Drastic problems, call for Drastic Measures. I recommend that President Trump, issue an Executive Order, Dis-establishing the Veterans Administration. Its a reduction in force, not firing. Work with GAO, to have all funds designated for the VA frozen and take immediate action to re-coup those funds back to the President as Discretionary Funds.Form a Task Force from Health Care Business Leaders. Find a way to utilize the recalled funds from the VA, to provide Medical Coverage for those Veterans who still need medical care. The best way to kill a dangerous snake, is to cut off its head. Tbhe VA snake somehow has the ability to immediately grow a new head.

  8. A friend came by and has been trying to get a, “comedy script” for a play. Over the last few months, he has come by and we share notes. Today, he comes by to let me read some of the script. No longer a comedy, it’s a satire. Not sure at all about what I felt, and was quite shocked to read the humorous view of the plight of so many Veterans. He’s informed by Ben and others. He knows how I feel. What we found wrong, is he assumed, many times, that Veterans have options. He thought if a problem occurred there is a way to appeal it. He assumed that appeal would be settled within ones life time. Point is; people don’t understand us. We are a category, not individuals. We, as an individual, need to make a good showing. They, need better understanding, and news sources. Each one of us, most likely, have some others in our lives. I need to make a difference. Thanks Ben, and y’all are making a difference.

  9. VA employees sleep well. No accountability, no meaningful investigations, no charges will be filed, no worries about jail time, and they will most likely be relocated so that things cool off.

  10. Perhaps off target, a man, Geoff Woo, wearing a health monitor and it’s amazing. It regulates, analyzes… This system may be the future in the VHA. Anything else that the VA would invest in will be a huge waste in taxpayers dollars. In no way am I suggesting this device has answers for VA employees conduct, but it covers a lot of health care answers for many of us. @Ben, another great, sickening post. How do these people sleep??… I know, too damn many of them are sleeping quite well.

  11. I believe Ben may have written a previous column on this, but this is the same hospital where 24 VA police officers filed a lawsuit after discovering hidden cameras and microphones in their control room and changing room in 2014.

    Maybe Hawkins is a pervert as well. Or someone was trying to find out whether other illegal activities we’re being investigated.

    The NBC article says both Hawkins and the police chief installed the cameras.

    Perhaps they won the lawsuit, and this IG thing is a cleaner way of firing Hawkins.

    1. Not a pervert. Just listening to who knew what about his corrupt clan.

      I have a record of prescriptions on my file for drugs I never received from the DCVAMC pharmacy.

      1. Lem, I suspect $150 million is the top of this corrupt iceberg if they wanted to dig deeper.

        I wonder how that lawsuit turned out since Chiefy Jerry Brown is still listed on their leadership page.

      2. @Lem @Namnibor – Please Gents, lets compromise, and I suggest, well hell no, I’m going to refer to all VA corrupted employees as, “Verts.” OK? Why waste the kinetic energy in pronouncing the full word. Get ready, there’ll be more articles of discoveries published by Ben, that’ll be coming down the pike. Make amends, shake hands, because these people [VA Verts] will keep on underservicing Veterans either by stealing, and/or hurting and killing Veterans. We have to stick together, in order to be organized for a full elemental surprise attack when they head to their high priced parking stalls. Remember, do them in ear to ear, go for both the carotid and the jugular. To be a success, we only need to get a few of them to get the fear started. Shhh . . . quiet now, as we wait in suspense to get those Verts.

  12. It’s encouraging to see what appears to be the IG crawling up the ass and giving a thorough, unannounced inspection of this hospital as shown by the time line, and how many seemed to have provided evidence.

    I guaran damn tee it’s happening everywhere.

    This kind of inspection should be happening, unannounced, at every VA hospital and clinic in the country.

    Whats discouraging is only the director has been reassigned to admin duties, as if a pencil pushing bureaucrat does anything else.

    He should have been fired as a start.

    If you read this, it shows a complete breakdown in management of that hospital. Where was the Chief of Staff? Chief of Nursing? Chief of Patient Safety? Whoever heads their purchasing?

    All of them should be fired! It should not take a nurse emailing the director to get things done right.

    It also shows a continuing lack of accountability because the incompetent director is the only one affected so far.

    The reassignment of this director is telling, and shows upper VA management had the authority to do this all along, but McDonald and others were too lazy to use it.

    I look forward to hearing that authority used more often.

    Since this went on since 2014, what kind of bonuses were paid out over the money the director was saving by not buying medical supplies?

    The only data I can find shows Hawkins was paid $179,099.00 in 2016.

    Nice salary for being incompetent.

    I applaud the nurse and others that came forward and hope this continues. If you look at the time line, it looks like the flood gates opened in reporting to the IG.

    Which makes me wonder, how many whistle blowers were retaliated against before the IG paid attention?

    As for firing, I can see at least one doctor that needs to be fired for using expired or unsterile medical equipment. So he did the surgery anyway? I bet that too happens at many VAs across the country.

    Finally, it pisses me off to know Shulkin dumped many millions into the self promotional Access to Care web site, and dumping many millions into their Suicide Search, but they don’t have enough money to buy medical supplies?

    Yeah, leadership priorities are all screwed up.

  13. Not surprising to me. I used the DC VA from 1995–2001 more than any other. The director is a political appointee not a qualified one. Things were going down hill during the time I used the DC VA. All that was happening was construction designed to have the directors name enshrined on a plaque. The director’s office was totally unresponsive to complaints. I was hospitalized in the nursing home for several weeks until I checked myself out because the orderly substituted aspirin for my T3. An aspirin has a very distinctive taste compared to Tylenol which doesn’t dissolve as quickly.

  14. Fuck the VA:
    ……..(‘(…´…´…. ¯~/’…’)
    ……….”…\………. _.·´

  15. Again, close the entire department down. Move it into Medicare and Social Security, along with its billions of $$$ in budget. Provide a class of coverage for Veterans of all ages and their dependents, provide them with ID and coverage, according to service if necessary, and include all Honorably Discharged. LET US GET QUALITY HEALTH AND MEDICAL CARE JUST LIKE EVERYONE ELSE!!!

    Simple solution. They will NEVER be able to fix the existing VA, never.

  16. Notice the VA just HAD to slip in that little annoying tidbit that this former director Hawkins is only on *temporary* administrative duties?
    He could sit like that for months while still collecting his director level salary…then once the news heat is off, which is about now, the VA will play the shell game of whack a mole and Hawkins will magically pop-up at the Phoenix VAMC, where it seems to be the dumping ground of VA misfits. Wait for it……..

    1. @Nam – – – Probably. But first he must do his “Tropical Vacation Penance” at the Manila Embassy Clinic on the taxpayers nickel. Worked for Rima Nelson. The VA formula seems to be “we’ve gotten away with it since BC was the POTUS. Why mess with success?”

      After he has had a suitable period of R & R – – – then he goes to Phoenix, which is probably considered “High Risk” duty in VA parlance . . .

  17. Isn’t something that the agency who promises us the map leading to the fountain of youth through advanced genetic research, cannot turn multiple billions of dollar slated to develop advanced computer predictive models of human behavior, and computers that can predict medical need before the patient presents with symptoms, into a simple tool to monitor the behavior of their own people in real time?

    How about doing research on corruption? We have a known quantity and known specimens from which to study, right? Experiment Alpha: Take half of VA persons and place them in prison. The other half place them on house arrest. Hire in 50% new specimens.

    Study will analyze efficacy of the treatment for corruption and adjust parameters accordingly.

    VA loves to study and I say say let them study this.

    1. Keeping in mind our obligations to the AFGE who might object to half their folks in prison, I would suggest that this is offered as a plea bargain option (if they force investigation we will take ALL the criminals to jail instead of just the set 50%)- a gift from The People.

      Somebody post me he damn beer makers contact! I have even more ideas that he is gonna want to hear!

  18. This is just one example of the systemic rot that permeates all levels of government in this country. It starts at the top with a corrupt political culture that rewards and encourages deceit and erodes any inference of honesty and integrity. America needs a reset

  19. The only reason the VA jumped on this so quickly is because it was NEXT DOOR! Sounds like UNITED! Oh! me so solly! The only difference is that VA won’t get sued. Just back to business as usual.

    1. 🙂
      The mainstream news media is still spinning cotton candy from this United Airlines dragging of passenger off plane debacle.

      Notice even a Veteran could set themselves on fire outside a VAMC but not a blip, and even when the VA gets caught screwing-up royally RIGHT IN THE D.C. Swamp, the news only remains in the forefront for maybe one eight hour shift…now…~~~~~crickets~~~~~ ~ ~

  20. I would recommend that the Director in Fayetteville Arkansas be investigated as well. He was the Associate Director with responsibility for logistics while most this happened. That is until he was promoted. Bryan Matthews. Look it up.

  21. I agree namnibor. Who sewed the balls back onto the OIG?

    That’s about the only thing that surprised me. If they found that much crap, what did they miss?
    For example;
    Where’d all the taxpayers monies go to purchase the much needed medical equipment and supplies?
    Where’d all the taxpayers monies go keep the medical supplies and equipment from being repossessed?

    I do believe this would constitute “Misappropriation of Government Funds!” Which, by the way, is a Felony!
    Punishable by lots of prison time!

    I also wonder IF this VHA received the dreaded “BONUSES” last year. Or, have they given/stolen taxpayers monies this year?

    And, as we all know – IF it’s occurring in Washington DC – it has to be occurring Nationwide!
    Think about this. If it’s happening in Washington DC, right under the noses of the “TOP BRASS” of VA, (Shulkin and others), then it’s definitely happening across the nation. Because, IF Shulkin says he didn’t know about this – (until the OIG report came out) – I do believe he’s a fuckin’ liar!

    Lastly; where will that director be transferred to? That’s VA’s standard operating procedures! Instead of prosecuting – they either transfer the criminals or allow the criminals to retire with full benefits!

    It’s time for a lot of VA employees to start going to prison!

    1. @Crazy elf- “[Lastly; where will that director be transferred to? That’s VA’s standard operating procedures! Instead of prosecuting – they either transfer the criminals or allow the criminals to retire with full benefits!]”

      Per VA standard operating procedures, I predict they will make this Hawkins Chief Dick in-charge of procurement of medical supplies for ALL of the VA…again, wait for it.

      *IF* Shulkin does something OTHER than play whack a mole and actually fire Hawkins’ ass, then and ONLY THEN, will I be fully impressed.

      One would think a director with last name of Hawkins would somehow personify the ever-watchfulness of a….Hawk.
      However, seems Hawkins was watching $$$ be saved at the expense of safety and Veterans. Where’s the $$$$…follow the $$$$$.

      Whomever Ben Carson used to fully audit the HUD just recently and found like Billion$ missing, the same should be done with entire VA and see where the beet is bleeding.

      Larger question: Had VA Sec. Shulkin *not* released on same day a news item of VA transparency website as this new scandal erupting, would Shulkin had acted so quickly or was this a move motivated by ego/id?

      1. namnibor,
        Ben Carson found, because of an audit, “OVER $500+ BILLION, (A HALF TRILLION DOLLARS), OF TAXPAYERS MONIES” in Fraud waste and abuse by HUD, (Housing and Urban Development).
        How’s that for doing something right!

      2. I think Shulkin acted simply because the HVAC committee is investigating.

        And they almost screwed that up.

        According to that NBC article:

        Shulkin yanked Hawkins and named the Chief of Staff who oversaw the mess as Acting Director, then changed his mind Thursday and named that retired Colonel.

        The VA press release was updated when that happened, but it claims the Colonel was from outside the facility.

        That is technically true, but the Colonel had been serving as a senior advisor. To Shulkin.

    2. According to an NBC Washington news article, the IG found $150 million in unaccounted for equipment and missing medical supplies.

      That article also says the IG received a complaint March 21, inspected storage areas at the hospital March 29-30, April 4-6, and again Wednesday.

      Why did Shulkin move so fast?

      Its an embarrassment to the House Vets Affairs committee.

      The chairman is quoted at the end of the article complaining about the lack of oversight at the facility.

      Thinking people would believe a lack of oversight by Congress as well.

      It says the committee has an active investigation into the hospital.

      Gee, Mr Congressman. When will you expand that to hospitals outside your backyard?

      1. “Gee, Mr Congressman. When will you expand that to hospitals outside your backyard”

        BINGO! Question of the century for the congress critters on Veteran Committees! 🙂

      2. Right on there 91Veteran! Great question! Expand Investigation and Audits to all hospitals. Everyone though, these investigations and audits would be going to infinity with never reaching the end due to the amount of corruption that is in the VA. All veterans though would very much appreciate an overhaul with reform. Overhauling the VA to reflect accountable, ethical, and humane standards would be about the greatest accomplishment for humanity ever achieved in this country. I am hoping Secretary David Shulkin’s leadership actions in this case is not just a one time show. Please Secretary David Shulkin carry on with draining the bad VA creatures.

  22. “[Why would Shulkin move to remove Hawkins so quickly?]”

    He was removed as quickly as this news story was scrubbed from the mainstream media news feed.

    1. DCVAMC already scrubbed his bio from their web site.

      A retired Army Colonel who served during the Gulf War as an LT is Acting Director. His service may have been as a Medevac pilot.

      He also had service with Command Inspector General, Army Med Department at Ft. Sam.

      Looks like at least one VA is going to get lit up.

      1. Darn Well About Time. Colonel Connell did a good job when he was at Tripler Army Medical Center.

        Hope he ignites a mass conflagration under their asses!

  23. I would venture to guess that this is just anothet typical VA medical center hard at work at killing us.

    I wiuld be ashamed to let people know I wirk for the VA … I mean stealing tac payers money pretending to work for the government.

    This shit should be included on every enlistment contract under the heading WARNING subsection your country does not give a shit about you

  24. “[I cannot help but wonder if VA leadership allowed these problems to fester right under their noses and could not detect the stench for years, how much is going on nationwide?]”

    The VA and Sec. Shulkin will further surprise me if they acknowledge they have a systemic problem in ALL of the VA System in USA. THIS is the opportunity to launch Operation Spring Clean at the VA.

    However, as much as I am thrilled that the director of this D.C. VAMC has been removed and placed on administrative duties, part of me also is worried that this will just be a one-time show of force to set an example, then left to fester again. Hope not.
    ALL management in that VAMC needs to be fired as well as the director because in all that time, those below the director could have reported this years ago but didn’t.

    Want to bet the aftermath will reveal they were funneling $$$ for bonuses or at least someone’s pockets?

    Also, want to bet employees stole and sold expensive medical equipment, perhaps even to scrapyards so they could get their next “fix”?
    I wonder how many Veteran Pharmacy mailings were *constantly lost in the mail* from this facility? How about drug testing each and every VA employee regularly to see the Skittles Rainbow in shades of yellow?

    Don’t be surprised if the NAACP gets involved with this and the VA and/or AFGE Union…I’m betting the now-deposed facility director will put-up one hell of a fight on this one….wait for it….the incredibly stupid are incredibly resistant to admit fault and then there’s ego to take into equation.

    Sec. Shulkin needs to realize that *if* the Nation’s Capitol’s VAMC is this poorly managed, then it should automatically be assumed that since Phoenix VAMC is still a terrible mess three years after scandal broke-out there, then Sec. Shulkin needs to open his mind to fact that we have a SYSTEMIC PROBLEM…roger that.
    Also keep in-mind as lengthy of a list of infractions are at the D.C. VAMC, those that made the list are more than likely a drop in the bucket and the VA OIG probably only listed the most grave infractions, literally.

    Sec. Shulkin—- Further show Veterans you mean business and not business as usual….FIRE EVERY ONE of the management at this VAMC for starts to place the fear of their rat bastard jobs…$$$$ and accountability are the VA’s Achilles Heal, so I say keep shining the light of accountability and THANK YOU WHISTLEBLOWERS!
    Rant Out. (Happy Good Friday, folks!)

    1. I forgot to ask this: Who sewed the balls back on the VAOIG since they were out of equipment to do so at this VAMC?
      Or, will the annual VA Easter Egg Hunt reveal all their balls were repurposed into colorful eggs?

    2. Hawkins can fight any punishment, but it looks like plenty of evidence has been gathered here. All of it against him.

    3. Namnibor, yes, agree with you. As for auditing all aspects of the VAs throughout the country, it really would be a great leadership decision if Secretary David Shulkin would hire many veterans who might could work, who are looking for work, and who want to contribute to
      reforming the VA healthcare system to where it reflects quality, top notch, and world class care. Many veterans may not be doctors but I am sure many veterans could be hired to audit all the VAs regarding all the supply inventories throughout our country. If a task force such as this was established, it would be a great investment that would assist the veterans in getting back into workforce and reduce veterans’ homelessness. This type decision would be a win win for the veterans and the VA. I know that I have recently read where Secretary David Shulkin is creating taskforces to audit the VA. So why not include the veterans? This could assist many veterans in getting back on their feet with pointing them in a positive direction. If Secretary David Shulkin will continue to lead with accountable, ethical, and humane decisions such as removing this director and if he will take action throughout the country such as this, Secretary David Shulkin will earn my respect. This is a must for the veterans to survive and to prevent the VA from collapsing. And too, if veterans had a part aligned with the OIG, then, there would be real accountability with transparency because it would involve many eyes. As for employees, disciplinary actions should take place if discrepancies are noted. The disciplinary actions could come in many forms or just one form as it depends on the severity of the situation. Thanks to Secretary Shulkin but he needs to keep it up and not drop the ball.

      1. The employee that stole my T3 was a veteran. Not much help there. It is the morality of the last several generations– the me first generations that want it all for themselves and the hell with anyone else. You remember them from your service. Some have your back and the rest fake it.

      2. Yes, Lem, you are correct about the morality issue with many in the past few generations but not all.
        There are a few here and there with upright moral and ethical standards. There are a few that show respect and dignity.
        Lem, though, you are right about the self seeking people whether they are veterans or non veterans. Some may have your back but some may not. One never knows because all human being are infallible. I guess at times it is just a judgement call. One point though with the more recent generations, it goes back to one’s upbringing with the moral foundation that they were exposed to when living at home with parents. Over the more recent generations, the family structure has deteriorated. I am referring to kids brought up by only one parent or no parent at all, not being exposed to what is right and wrong, not having the opportunity to learn a good work ethic, not having been disciplined with being shown the mistakes while simultaneously shown with how or what could have been done instead, kids not having to learn in school, and too it even points straight to government run schools with common core being used in K-12, reflects on what the students are being taught by these unionized teachers with the teachers unions letting the teachers do whatever, which is exactly like the VA union, so really the morality breakdown of people in the more recent generations is due to a breakdown in our culture as a country. Most points directly to Democrat policies / Liberalism that do not honor law and order. They point directly to political activitism with protecting and not exposing corrupt morality to hold people accountable. So yes, Lem, you are right. One never knows who can be trusted or not trusted this day and time.

  25. Does anyone know if you can use a private hospital ER if you have an emergency? I wouldn’t want to go to the county hospital ER for an emergency.

    1. I was wondering if the VA would pay for a private hospital ER or if you have to go to a government/county hospital ER?

      1. You can, but …. In addition to the 72 hour thing, I’d recommend having a chat with the local ER/Hospital director to see how the VA responds to requests for payment. The hospital will hold YOU responsible. My neighbor ran up about $90k for an ER visit and a 250 mile life-flight/air-ambulance. The VA paid it – after 2.5 years. Here’s a guy with a heart condition and the stress of demands for payment was not healthy. But – the VA did pay. A more recent event requiring a flight from the same local ER to the same VA facility on the same life-flight – 90 days to pay. The difference? Who knows? But, there has been new management at the VA facility with noticeable positive changes.
        As always, your mileage may vary, batteries not included, and your elected officials don’t give a shit in an off-election year.

    2. Lily, you’ll need to read this Fact Sheet. You have 72hrs to contact your local VA after using emergency services. “”

  26. Good Aritcle Ben.
    I am neither shocked nor surprised at this. I read the complete VAOIG Report yesterday evening. I also e-mailed it to an ER Trauma Nurse friend of mine, and asked her to provide her thoughts on what would happen if HER hospital were caught operating the way the VHA does. When I receive her feedback, I will include it verbatim in a future comment.

    More tragedy, lies, and deception from VA leadership – – – who just see minor fires to be put out at individual VA locations across our land – – – rather than recognize that it is their “leadership” as in lack of, that is where the problem begins.

    Why in the hell does the VA spend millions of dollars on television and radio commercials misinforming veterans, and the public – – – about how great the VA healthcare is?

    They are always showing what looks like a combination of Club Med, Shangri-La, and Queen’s Medical Center. What they should be doing is paying their VA CHOICE bills, so VETERANS DON’T HAVE TO DEAL WITH COLLECTIONS and have their CREDIT go down the drain.

    The current, continuous push to show the VA as a model Healthcare system is highly disturbing. My gut tells me this is all about giving the VA a facelift on the same old witch. More Lies and Deception.


    1. Recognize the problems inherent in the VA are SYSTEM-WIDE, not jus limited to a few locations.

    2. Fire all the Lazy No Good Workers. Fire EVERY single AFGE/SES Employee.

    3. Sell off all the VA facilities. Alternatively, they may be converted into housing for homeless veterans.

    4. Issue all veterans a card that allows them to choose their own doctors within their community that they can TRUST.

    5. The United States Government will PAY those doctors promptly for the care they provide veterans.

    6. Completely ELIMINATE the “Federal Protection” Umbrella for incompetent QUACKS that the VA sends to other states to practice other than their own. Gonna practice in Hawaii? You need to be LICENSED in Hawaii. Same applies to all other states.

    And Thank You for getting the comments notification and follow selections fixed.

  27. @Ben, no i am not shocked that this existed under the nose of senior leadership. My experience has been that senior leadership are involved with covering up all kinds of deficiencies in a va medical center. The part that surprised me is that vaoig had done an audit and was specifically identifying the logistic and inventory control problems and bio-med and did a follow up. Secretary Shulkin taking action was different with the removal usually comes from visn or vaoig. I doubt any legal action will be taken on this director.

    If va employees were doing their jobs responsibly these errors would not be occurring. The supervisors of purchasing, bio-med and supply are also responsible. Va leadership failed on so many numerous levels concerning these issues. Missing medical center equipment is not an issue in most va medical centers. End of surveys are not usually done annually for missing or lost equipment and service line chiefs are not held to any financial responsibility even though directives state they are responsible financially for the missing equipment.

    I hope they will straighten up the known deficiencies and fire some individuals for allowing this risk for potential endangering a Veterans life and i hope no Veteran was harmed for these negligent acts.

    Ben, do you think Secretary Shulkins would fire doctors/providers for putting Veterans lives at risk or for negligence and manipulating the system to deny Veterans rights to medical care? Or is this just a one time show of some use of authority?

    1. Spot on Exva. There are many more responsible for the mess this hospital is in.

      Including any provider using unsterile or expired equipment anyway.

  28. P.S. The director should be in jail…Not on “administative duties” still drawing a salary while they “investigate” (read ” find a way to cover it up” )

  29. The money to be used for the inventory was going into someone’s pocket.

    Also, Ben,

    It’s been over two weeks. Are you planning on taking my case or not?

    1. He doesn’t take any cases from Veterans. I informed him of an assassin in the VA system and he flat out ignored it.


      Somebody needs to have a very serious talk with a person who manipulates Veterans for their own gain.

  30. This hospital can’t perform the basics…Can’t order and stock supplies and can’t pay for them in time to keep them from being repossessed, Can’t keep sterile supplies separate from non-sterile…

    Shouldn’t be surprised…They can’t get that most basic of services ( answering the phone ) don’t expect them to get the rest right…

  31. That’s why I’ve never been to the VA. I would rather go to an emergency room locally. Let the VA reduce my rating for not using their care. I would rather live.

    1. Yes, I agree wholeheartedly. What a mess? Every facility needs to be gone through with a fine tooth comb just like they did with this VA. I am serious. Even, all the medical providers in all facilities need to be audited as to make sure all of their licenses are up to date and not expired.
      The VA budget needs to be done the very same way with auditing every single dollar to determine what, where, when, and how each and every dollar is being allocated and spent. I am shocked to hear that Secretary David Shulkin acted promptly to relieve this VA director. This is the first time in all my years and years and years while in the VA that I have ever heard about the VA acting on anything in punctual manner. I very much appreciate Secretary David Shulkin’s leadership decision on this issue. Thank you Secretary David Shulkin for now trying or attempting to try do what is accountable, ethical, and humane. I am not surprised at all about the VA in Washington DC being found this way. I am even in a least problematic VA and I have witnessed nurses not wearing gloves, doing IVs this way, eating next to a patient after handling whatever. The cleanliness protocol in these VAs among providers does not reflect high standards at all. It is not a wonder that not only the veterans are sick but the employees and everybody around them are sick too or become sick due to the poor hygiene protocol that is followed. Of course though, I have not received any treatment from the VA in close to 9 months. I have moved all my care out of the VA except for one of my SCs. So I do not know if they have improved the protocol at all. Best, All.

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