Nonconforming surgical instruments reprocessed and used at Carl Vinson VA, according to a March 2025 OIG report.
By Alyx Arnett
A March 2025 report from the Department of Veterans Affairs Office of Inspector General (OIG) has found that staff at the Carl Vinson VA Medical Center in Dublin, Georgia, reprocessed and used surgical instruments with visible damage, despite policies prohibiting such practices.
The report was prompted in part by a spring 2024 incident in which surgical tools with visible damage—including staining and pitting—were discovered in a rectal tray that had already been used during a patient procedure. While it remains unclear whether the nonconforming instruments were used on the patient, the entire tray had been reprocessed and returned to use, and staff failed to remove the visibly damaged tools prior to the procedure, according to the report. According to VA policy, if one item in a surgical tray is contaminated or nonconforming, the entire tray is considered compromised.
The event occurred after a prior inspection in 2022 had identified similar issues at the facility and after VA leaders had agreed to implement corrective actions.
During the latest inspection, OIG staff found additional nonconforming instruments in randomly selected surgical trays and determined that reprocessing and using visibly damaged tools was an ongoing practice at the facility. According to the report, both current and former Sterile Processing Services (SPS) chiefs allowed the practice, citing factors such as pressure to deliver complete trays, unclear responsibility for instrument replacement, and what one leader described as “staff complacency.”
Training Delays and Policy Noncompliance
As part of its review of the rectal tray incident, the OIG assessed how facility leaders responded after the damaged instruments were discovered in spring 2024. According to the report, the chief of SPS conducted refresher training for sterile processing staff and posted visual reminders in the work area. However, operating room staff did not initially receive similar training, despite internal documentation noting the need for “more rigid inspection” of surgical equipment.
When asked why this training was delayed, the operating room nurse manager cited limited staff time and expressed concern about leadership deprioritizing essential safety efforts, according to the report. The OIG described the lack of timely training as inconsistent with expectations and a missed opportunity to prevent continued use of damaged instruments.
Preventive Maintenance Program Missing Until 2024
Inspectors also found that the facility had failed to implement a preventive maintenance program for surgical instruments, despite a 2016 VA policy requiring one. The program, which involves routine sharpening, repair, and replacement, was only put in place in May 2024 after years of leadership turnover, according to the report.
During initial servicing under the new contract, more than 800 surgical instruments were identified as “beyond repair,” including four from the same rectal tray involved in the spring 2024 incident.
Incomplete Fixes from Prior Oversight
The March 2025 inspection also assessed the facility’s progress on recommendations issued in an earlier March 2024 OIG report. Key corrective actions remained incomplete:
- CensiTrac, an electronic instrument tracking system, had not been fully implemented. OIG found missing documentation, unmarked instruments, and discrepancies between instrument trays and count sheets.
- The CensiTrac coordinator, responsible for overseeing the system and instrument marking, had longstanding performance issues that were not formally addressed by supervisors.
- A room meant for training and meetings continued to be used for meals and breaks, raising contamination concerns. Despite verbal claims of repurposing, inspectors observed food and drink in the room during their visit.
The report cites high leadership turnover as a major contributor to the continued deficiencies. The SPS chief position changed hands four times from early 2022 to late 2023. At the time of inspection, all members of the executive leadership team were serving in acting roles, according to the report. Separately, the VISN chief sterile processing officer noted poor communication and unfilled critical positions within the SPS department.
Recommendations and Response
The OIG made five new recommendations:
- Ensure proper identification and removal of nonconforming instruments.
- Provide training for operating room staff on recognizing nonconforming tools.
- Review whether any patients may have been affected by the approximately 800 nonconforming surgical instruments.
- Evaluate whether administrative actions are warranted for staff involved in the deficiencies.
- Strengthen oversight of corrective actions and ensure long-term compliance.
Leaders from both the Carl Vinson VA Medical Center and the VA Southeast Network—which oversees the facility—concurred with the recommendations and submitted action plans. The OIG stated it will continue monitoring until all corrective measures are complete.
In a statement to 24×7, a representative from the Carl Vinson VA Medical Center says the facility is working to address the issues outlined in the OIG reports: “VA is under new leadership and is committed to solving the kinds of problems highlighted in these two OIG reports, which resulted from inspections in 2022 and 2024. The Carl Vinson VA Medical Center and VA Southeast Regional Network are well on their way to addressing all the recommendations in the reports.”
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