Deficiencies in Leaders’ Responses to Lapses in Reusable Medical Equipment Reprocessing at the Chillicothe VA Medical Center in Ohio

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing procedures. During the review, the OIG also identified concerns related to actions taken by Veteran Health Administration (VHA) leaders. The OIG received three similar complaints alleging that a facility SPS employee (employee) improperly reprocessed endoscopes, placing patients at risk. The OIG requested facility leaders respond to the allegations and provide information regarding SPS procedures, staff compliance, corrective actions, and reports of patient harm. The facility response revealed that after becoming aware of the allegations, the Chief and Assistant Chief of SPS conducted an audit of endoscope reprocessing supplies and found discrepancies with the supply use documented by the employee. Further, facility and Veterans Integrated Service Network (VISN) investigations substantiated that the employee did not follow facility reprocessing procedures and falsely documented compliance. The OIG determined that the Facility Director did not develop and implement an adequate plan to monitor the employee’s compliance with SPS procedures following reinstatement to SPS duty, particularly given concerns regarding the employee’s integrity and compliance. Because multiple patients were potentially affected, facility and VISN leaders notified the VHA Clinical Episode Review Team (CERT) for review and disposition. The CERT concluded there was minimal risk to patients and that a large-scale disclosure was not warranted; however, the OIG found that the CERT’s determination may have been based on an inaccurate understanding of the reprocessing equipment’s capabilities. The OIG made one recommendation to the Facility Director regarding oversight of the employee’s performance. The OIG made one recommendation to the Under Secretary for Health regarding the CERT’s review of OIG-provided information to determine if it altered the determination of patient risk or the need for a large-scale disclosure.