Toilet Water Dripping in Surgery Rooms at VA Medical Center Prompted Inspections; Other Problems Alleged in Letter
Backed-up toilet water on the fifth floor of the Carl T. Hayden VA Medical Center in Phoenix dripped into rooms where surgery was occurring this summer -- twice.
The dirty secret was revealed in an anonymous letter we received yesterday that outlined less-than-admirable conditions at the hospital complex, which is located at 7th Street and Indian School Road.
When we called the VA center to check on the allegations, we learned that the letter may have embellished the truth. But only a little.
Bottom line: Medical center staff say the problem was fixed and no patients were harmed by it, but the September 27 letter still raises serious questions.
It reads, in part:
Multiple surgical patients have had raw sewage drip in them during surgery at the Carl T. Hayden VA Medical Center in Phoenix, Arizona.
This has happened twice in the last six months that I am aware of an absolutely no corrective action has been taken. The first patient was a vascular surgery patient of Dr. Vivienne Halpern, Chief Vascular surgery. The second which happened in late July belonged to Dr. Howard Bourdages, a general surgeon at the VA.
I can you the Leadership of this medical center knew of the first case, covered it up, which allowed the second case to happen. As a result of this neglect, the VA Office of the Inspector General was at the Phoenix VA to investigate this and 4 other wrongful deaths 2 weeks ago.
The situation is so dreadful the OIG is sending in a second team to assess the conditions of the surgical units and staff. The results of this next visit could be the end of the medical center performing surgery on Arizona veterans.
The liquid wasn't "raw sewage," says Paula Pedene, the VA public affairs officer in Phoenix.
True, it was toilet water -- but it was clean toilet water, she says. She couldn't confirm whether any splashed directly into the open surgical wounds of the patients, as the letter suggests.
The fifth floor houses mentally ill patients, Pedene says, and the incidents stemmed from one of those patients "having issues and acting out."
"He was putting extra paper towels in the toilets during his hospital stay," she adds. "It happened two different times -- he plugged up the toilets."
Pedene huddled with the VA medical center's staff this morning and crafted a reply to our questions about the letter. Here's what they wrote:
Due to a plugged up drain on the fourth floor, which is over the Operating Room Suites, the PVAHCS had two plumbing leaks that affected surgeries. This happened on two separate occasions.
PVAHCS responded immediately with corrective actions and sealed the penetration points between the 4th and 3rd floor directly above OR 5 alleviating any further such outcomes.
Both patients were notified of the issues during their surgeries and no adverse outcomes were noted.
Two Investigative Teams reviewed the leak issues and potential impact on VA surgeries. The first team was from the Office of the Inspector General (OIG) Aug. 16-19, 2010 with a conclusion that there was no compromise to patient care.
The IG investigation was in response to a complaint by an anonymous disgruntled employee. Because the issues raised were so concerning, the PVAHCS requested a second, separate independent review from the Surgical Review Team from VA Central Office which was conducted on Sept. 29. Their conclusion was consistent with the OIG Inspection again finding that no patient care was compromised.
We put in a FOIA request for documents related to the OIG findings and will follow up this story when we hear back.
A couple of follow-up questions we asked:
* What about the allegation of at least four "wrongful deaths?"
Pedene got back to us quickly on that one, writing in an e--mail that "both the OIG and the VA Central Office Surgical reviewed the deaths and came to the conclusion that no patient care was compromised."
* Why did the VA wait until the second yucky dripping to fix the problem?
Pedene is still working on that one; we'll update this post when the VA answers.
We don't know yet exactly what all this means. The Hayden center is no Walter Reed, as far as we know. But this story requires more legwork, which we're more than willing to do.
We've heard great things about the doctors, nurses and other staff members at the VA -- in fact, we know someone who had minor foot surgery there just this morning. (Hi, dad!) This person reports that staff members are incredibly nice -- and that no toilet water dripped on him.
Pedene recommends that anyone wanting to compare the conditions at local hospitals can go to the Web site, www.hospitalcompare.hhs.gov.
We'll add that anyone wanting to tell us about conditions at local hospitals, (especially the VA, as long as it's on our mind), can e-mail us at firstname.lastname@example.org.