The U.S. Office of Special Counsel (OSC) today alerted the President and Congress that officials at the U.S. Department of Veterans Affairs (VA) West Los Angeles VA Medical Center (West Los Angeles VAMC) have taken appropriate steps to mitigate unsanitary conditions in operating rooms (ORs) that resulted in the cancellation of dozens of patient surgeries. A whistleblower, who is a neurosurgeon at the facility, disclosed to OSC that several ORs had been closed due to a fly infestation and sewage water leaks between March 2016 and November 2017.
The agency substantiated the allegations, finding that the facility's main entrance doors had been left open at times, which allowed flies to enter, and that VAMC leadership failed to appropriately monitor the presence of the flies. Additionally, the investigators found debris, a pipe leaking water onto the floor, and a wet/dry vacuum cleaner full of debris in the interstitial space between ORs and the dialysis unit. A rodent carcass covered in hatched larvae was also found outside the building and removed, and the area was thoroughly inspected. During this period, 40 surgeries were cancelled.
The agency further substantiated that since 2016, water leaks have caused the closure of multiple ORs and the cancellation of patient surgeries. The investigation found no evidence that any of the patients whose surgeries were cancelled experienced adverse outcomes because of the delays.
In response to the agency's report, the West Los Angeles VAMC contracted an entomologist and pest controllers, installed fly lights, and consulted with the VA Central Office to eliminate the flies. The facility also repaired the leaks and is preparing to replace all the pipes in the interstitial space. In addition, the facility installed forced air curtains at all entrances to prevent flying insects from entering the building, increased the cleaning frequency of drains, and installed trash compactors throughout the facility to prevent the breeding of flies.
“Thanks to the whistleblower's important disclosure, the agency has implemented all recommendations and is taking appropriate steps to mitigate unsanitary conditions in the operating rooms," said Special Counsel Henry J. Kerner. “While this has been a long process, the investigation resulted in significant improvements to the facility that will better ensure the safety of veterans undergoing surgical procedures."
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