VA says unclean clinic room was wrongly used to mitigate long wait

SALT LAKE CITY — A highly scrutinized unkempt examination room that recently greeted a patient at the Veterans Affairs campus in Salt Lake City was used in order to end the man's long appointment wait as quickly as possible, but shouldn't have been, officials there said Monday.

Army veteran Christopher Wilson visited Veterans Affairs for an appointment on April 5, finding a room with an overflowing trash can, a large bowl filled almost to the top with plaster and water sitting in a sink, and some supplies left out on a counter. His father shared pictures of the room on Twitter Friday, leading to more than 16,500 retweets and more than 2,400 comments by Monday afternoon.

Dr. Karen Gribbin, chief of staff at Salt Lake City's George E. Wahlen Department of Veteran Affairs Medical Center, said Monday that Wilson was taken to an area used to make and place casts for veterans with diabetic foot ulcers and that "normally that room is not used" for other patients such as Wilson.

"This particular day, the afternoon session was (especially) busy," Gribbin said. "Unfortunately, Mr. Wilson was taken into this room in an effort … to expedite this appointment."

Gribbin said she can empathize with the urgency experienced by medical staff who "feel the frustration of the veterans that are waiting," but despite that, "Mr. Wilson should not have been placed in that room."

"I and the entire facility apologize to him for that experience," she said.

Staff all across Salt Lake's Veterans Affairs health campus can expect to be in talks with leadership about "expectations of how we interact with our patients, how we make sure our environment is appropriate," Gribbin announced at a press conference Monday.

"We need to step back and look around and make sure our environment is a caring environment," she said.

Wilson said Saturday that he was surprised he wasn't moved to a different room.

"I figured they would say, 'Oh, this room's not clean' and take me somewhere else, but they just kind of blew past it, didn't acknowledge it," said Wilson, who spent six years in the Army and was deployed to Iraq twice. "They're doctors, right? So I figure one of them was going to say, 'Let's go somewhere else' or 'Give us a minute to clean it,' but nothing."

Wilson was at his appointment to get 18 injections around his ankle in treatment of a service injury he suffered in Iraq. Staff apologized for the wait time but didn't acknowledge the unclean condition the room was in, he said.

"When you think medical (office), you think sanitary," Wilson said at the time. "I've never experienced anything like that."

Wilson had waited about 45 minutes to be placed in a room, which he called fairly typical.

Gribbin promised Monday to look at the "flow through the clinics to see if there are opportunities to optimize, to make improvements, so that patients aren't waiting as long, so that staff don't really feel that pressure … and maybe take (a patient) to an inappropriate clinic room."

Gribbin conceded that "sometimes patients have waited a while both to get an appointment and then to get seen" by Veterans Affairs providers in Salt Lake City. She said the federal agency's Salt Lake system saw a 26 percent increase in unique patients been fiscal year 2012 and fiscal year 2017.

"We have had a huge growth. That is a significant growth and we have had some challenges that come along with it," Gribbin said. "That's a good problem to have, but we are busy."

Related:

VA hospital launches inquiry after tweets from veteran's dad about 'unsanitary' room

After photos of an unkempt patient room at a Veterans Affairs clinic in Salt Lake ignited angry reactions, a top administrator there said the facility is investigating.

Gribbin said she believes Wilson's unclean room "was an aberration." Asked whether the new inquiry would actively look for patterns of additional rooms having been left unclean for patients, Gribbin said, "We are talking with staff across the board and making sure we are all on the same page."

"This has certainly opened our eyes to make sure that we take a good hard look across the board at this issue," she said.

Gribbin said it was too early in the inquiry to answer definitively whether any staff could face discipline.

Stephen Wilson, whose tweet showing photos of his son's unclean room quickly evoked upset responses, said he is not satisfied with an internal investigation of how the incident occurred. On Twitter, he mused about whether the Veterans Affairs inspector general or the federal Occupational Safety and Health Administration should launch inquiries.

"It (is) not something I want to see my son subjected to again or any other veteran," Stephen Wilson said.

He added that "at first, I was sad for my son being subjected to those conditions, and then it made me angry."

Stephen Wilson said he worries his son could have been subjected to the risk of infection by virtue of the room was placed in, adding "diabetic ulcers are by nature open wounds."

Gribbin said she would characterize the room as "unsightly" rather than unsanitary, saying the casting equipment left in the room "would not be used on a patient there for a completely different (procedure)," such as Christopher Wilson.

Gribbin also said Saturday that "there (are) not other types of debridement or surgical removal of tissue" associated with the casting procedure that had happened in the room and that as a result, "I do not believe Mr. Wilson was exposed to any dangerous body fluids or blood."

Gribbin said Salt Lake's Veterans Affairs health campus is "has enjoyed an excellent reputation nationally and locally," and has "scored very high" on cleanliness metrics.

"I think the saddest thing to come out of this is the damage to that and the potential damage to the trust that our veterans have in us," Gribbin said.

Contributing: Ladd Egan

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