In December of last year, reports emerged that the Tomah, Wisconsin VA facility had possibly failed to adequately care for patients. Tomah isn’t new to scandalous behavior, as it’s the sight of massive over-prescribing of narcotics and therefore nicknamed “Candy Land.” But last year we learned that a dentist in the Tomah VA may have been using his own equipment in the facility, not sterilizing that equipment properly, and possibly exposing veterans to multiple bloodborne pathogens.
Those reports turned out to be true, according to a review by the inspector general released this week. When questioned, the dentist in question stated that he had used non-VA equipment that he sterilized by “spraying it with Virex and leaving it wet for 5 to 7 minutes; he did not send his unsterile burs to Sterile Processing Services (SPS) for sterilization.” This practice had taken place for about a year, potentially exposing 592 patients to bloodborne pathogens.
The review states that a dental assistant had noticed the use of unsterile equipment and reported that to her supervisor, at which point she was referred to the dentist’s supervisor. She then claimed “fear of reprisal” and didn’t speak to leadership about the issue until months later. The report goes on that other staff members noticed the dentist’s unhygienic and unprofessional behavior that doesn’t seem to have been addressed such as “not always washing his hands or wearing appropriate personal protective equipment” and the appearance that he was “occasionally sleeping at his desk.”
The quality of care issues here are concerning. The fact that staff didn’t raise those issues or feared retaliation is equally concerning. The review states that once leadership knew about the dentist’s actions, the dentist was removed from his duties and eventually resigned. But poor practices and a lack of concern for patients has proven to be a prevailing issue throughout the Tomah VA.