The U.S. Office of Special Counsel (OSC) today alerted the President and Congress that the U.S. Department of Veterans Affairs (VA) is taking steps to ensure water used in dialysis treatment is adequately tested for chlorine levels after a whistleblower at the John L. McLellan Memorial Hospital in Little Rock, Arkansas alerted authorities of inadequate testing. The whistleblower, a health technician, alleged that VA nursing staff failed to conduct and record the results of chlorine concentration tests of dialysis water systems. The whistleblower also alleged that VA employees regularly consumed food and beverages in the dialysis unit clinical area, in violation of agency policy.
It is vital to ensure water used to perform dialysis is safe and clean because patients can receive between 300-600 liters of water per week. In accordance with health and safety procedures, VA policy outlines that chlorine tests should be conducted in the morning prior to dialysis treatment, once every four hours thereafter, and at the end of the work shift.
An investigation conducted by the VA's Office of the Medical Inspector substantiated these allegations, finding that VA employees did not consistently conduct or record chlorine concentration tests of the dialysis water systems. The investigation also found the presence of food and beverage in the dialysis unit clinical area.
In response, the agency implemented corrective actions including updating the facility's standard operating procedures for chlorine testing of the dialysis water systems and by conducting an audit of the testing log until achieving 100 percent compliance for six consecutive months. In addition, the agency is providing education to staff concerning dialysis procedures and the prohibition on food and beverage in designated clinical areas.
“I thank the whistleblower for coming forward with these serious allegations," said Special Counsel Henry J. Kerner. “Patients undergoing dialysis are often immunocompromised and at a higher risk of infection. Because the whistleblower spoke up, steps are being taken to protect patients by ensuring the dialysis water system is tested regularly and the hospital's clinical areas are kept clean."
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