VA Hospital Confirms Water Leak on Surgery Patient, but Blacks Out "Quality Assurance" Documents

Categories: Medical Waste

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The Carl T. Hayden VA Medical Center in Phoenix has finally confirmed what an anonymous source told us back in October:

Backed-up toilet water really did drip into the open surgical wound of a veteran on an operating table.

Still, we're not terribly impressed with the records received from the VA hospital. Not only did it take the VA two months to satisfy our records request, but many of the documents we requested were completely blacked out.

Annoyingly, the hospital only released a written brief on one of the "drip" incidents, despite issuing an October press release that explained how the problem occurred on two separate occasions, to two separate patients.

Our records request had asked for all documents related to the drippings, so it looks like the VA is holding back records related to the second incident. As we mentioned in October, an anonymous source tells us that water drips actually occurred four times.

One question we'd like answered is how much time elapsed between the first and second incident, and why the problem wasn't fixed the first time it happened.

The "issue brief" we did receive explains how on August 9, water from the ceiling dripped into the surgical area while a 69-year-old veteran having a gall bladder operation.

"The leak also affected the anesthesia supply room," the brief states.

The operating table was moved to another room, and the surgery turned out okay -- following extra doses of antibiotics both during and after the operation. The patient recovered quickly and repeatedly praised the surgery nursing staff, though it's unclear if that was before or after he knew what had happened.

The brief states that the patient's physician later disclosed the disgusting truth to him. The veteran was instructed to return for "frequent clinic visits" in the weeks after the surgery "for possible wound infection."

On the same day as it occurred, top officials at the hospital were informed about the problem and an "action plan" was put into place to stop it from happening again. The hospital previously confirmed to New Times that the plumbing mishap was caused by a mental patient on a higher floor who stuffed a toilet with paper towels.

The action plan called for the sealing of all possible places where water leaks could occur above the surgical rooms, and for smaller amounts of toilet paper and paper towels to be kept in patient rooms.

In the meantime, engineering design work has already begun on a plan to replace the hospital's entire plumbing system.

"Where possible, drain pipes will be rerouted away from the OR," the brief reads. Officials estimate the plumbing project will be finished by this time next year.

Another issue brief we received dates from July 22, and refers to "numerous allegations" regarding the quality of surgical care at the hospital. We can't tell you what kind of action or comments were taken concerning these allegations, because that part of the brief is blacked out. The brief does claim, however, that "the evidence does not support the allegations."

A third brief refers to a team that conducted a "thorough review" in late September of the hospital's surgical services.

"Upon completion of the inspection, an exit briefing was conducted for leadership," the brief states. Everything that follows in the two-page brief is blacked out. Apparently, we're supposed to believe the hospital's press release in October that states that the team concluded there was "no compromise to patient care," even though the hospital redacted the document that might back up that statement.

Mary Monet, the VA public records officer who fulfilled our request, wrote in an accompanying letter that information was redacted to comply with a law disallowing the release of medical quality assurance records. The law's meant to allow people to freely talk about each other without having to worry that what they say will be disclosed to anyone. Former Pennsylvania Congressman Joe Sestak had been pushing for a bill to make the agency more transparent, but he was voted out of office in November.

Monet promises to get back to us this week with more information on the second drip incident.

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Federal law allows the U.S. Department of Veterans Affairs to withhold the release of medical quality assurance information.

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I recommend anyone with an interest in this issue should volunteer at the VA Hospital. Call the Veteran's Administration's Volunteer Services coordinator at 602-686-1199. These people need our help and assistance - obviously the government (read the administrators at the VA) isn't doing a good enough job and they're unable or unwilling to ask the congress for additional monies to address this issue.

BTW - I heard the Director of the VA at a recent hearing, when asked by a congressperson if he had everything he needed to accomplish his mission say: We have all we need. REALLY!

Bladed Madmax
Bladed Madmax

This is disgusting. This is no way to treat any person let alone a veteran who has sacrificed by serving our country. The people who are responsible at this hospital should be forced to do some service overseas in harms ways so they understand that our VETS are not treated this way.RM1 USN Retired


The Director of The VA is really in over his head. He recently sent a memo to all staff describing that there was a major budget issue at the Phoenix VA due to unanticipated (read - inept upper management and fiscal irresponsibilty on the finance team) fee for service cost overruns. Because of this budget issue, all departments have to give up 12% of salaries - that means no new hires to fill vacancies and no overtime to cover work that needs to be done. End result, patient care suffers - just go to the emergency room any night and you will see patients waiting for 10 hours and more to see a doc. Remember, this is at a time when the VA at the national level keeps asking for more and more funds each year and rightfully keeps getting them! So, why is the Phoenix VA cutting back staff and services? Has to be the management.

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