Report Summary

Title: Healthcare Inspection – Review of Improper Dental Infection Control Practices and Administrative Action, Tomah VA Medical Center, Tomah, Wisconsin
Report Number: 17-00712-366 Download
Issue Date: 9/7/2017
City/State: Tomah, WI
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted a healthcare inspection at the request of Senators Tammy Baldwin, Chuck Grassley, and Ron Johnson, and Representatives Ron Kind and Timothy Walz, to assess improper dental infection control practices and administrative action taken by the Veterans Health Administration (VHA) at the Tomah VA Medical Center, (facility) Tomah, WI. These practices potentially exposed 592 veterans to bloodborne pathogens (BBP), including human immunodeficiency virus and hepatitis B and C viruses.

Facility leadership were unaware of the improper infection control practices until October 2016, when acting supervisor Dentist B reported to the Chief of Staff that Dentist A (hired in October 2015) used a non-VA unsterile bur during a dental procedure. Two factors that contributed to facility leaders not being aware of Dentist A’s improper infection control practices sooner were (1) failure of staff, despite safety and infection-control training, to report Dentist A’s breach of infection control practices, and (2) advance notification and other issues associated with Dental Clinic inspections.

We determined that the facility, Veterans Integrated Service Network (VISN) 12, and VHA took appropriate follow-up actions and responded timely to patients’ potential exposure to BBP. The facility removed the non-VA unsterile bur from the operatory, reported the incident to Human Resources, briefed VISN 12 leadership, and directed Dentist A to leave the clinic. Dentist A subsequently submitted a letter of resignation. The Deputy Under Secretary for Health for Operations and Management convened a clinical episode response team (CERT) to identify steps to take in response to the potential exposure of patients to BBP which included identifying, testing, and treating patients. Facility leaders made timely large-scale disclosure to 592 patients and flagged patient EHRs as needed to alert primary care physicians to discuss follow-up.

We made one recommendation to the VISN 12 Director and four recommendations to the Facility Director.