Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic

The COVID-19 pandemic caused a surge in demand for ventilators and provoked concerns about potential supply shortages across VA medical facilities. During the course of a previous broader review, the VA Office of Inspector General (OIG) uncovered a potential issue with the number of ventilators procured and stored at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, and sought to determine whether they had been properly requested, acquired, received, and accounted for. The OIG found the facility acquired more ventilators from March 1, 2020, through November 30, 2021, than were needed for veteran care. Facility and Veterans Health Administration (VHA) officials duplicated purchase efforts, resulting in the facility obtaining 112 ventilators—56 from a local contract and 56 from a VHA national contract. This was due in part to facility officials’ concerns about the pandemic-related demand and acquisition delays from supply chain disruptions. The VHA-purchased ventilators, worth about $2.5 million, were never used for patient care at the hospital. They were placed in storage for more than 19 months during which other VA facilities reported shortages. The ventilators were quickly redistributed in 2022 after facility officials turned them in. The hospital lacked an effective methodology to determine the number of ventilators the hospital needed either before or during the pandemic. Contributing to these issues was VA’s lack of a reliable inventory system to identify excess equipment. VA concurred with the OIG’s recommendations to (1) document a methodology for determining the number of ventilators required to fulfill the facility’s mission during routine and emergency operations and (2) determine whether the remaining ventilators are all needed or can be turned in as required by VA policy. VA submitted documentation of corrective actions resulting in the OIG’s closure of the recommendations as implemented.