The report is the result of a December 2010 review of infection control issues at the Dayton VAMC. That review stemmed from a VA Clinical Review Board's investigation of allegations that, over an 18-year period, Dwight Pemberton, DDS, performed invasive dental procedures on patients in the Dayton VA dental clinic but failed to change latex gloves and properly sterilize dental instruments between patients.
According to the report, clinic employees said dental instruments weren't properly cleaned between patients, sterilization was skipped even if instruments were used on dentures with blood, and that Dr. Pemberton at times answered his cellphone or drank coffee with his gloves on. Employees also told investigators a supervisor had been notified but didn't respond.
"We found evidence of lack of adherence to proper infection control policies and determined that the subject dentist did not comply with infection control and related procedures," the report noted. "We identified evidence that Dental Service management was aware of these infractions prior to the SOARS [System-Wide Ongoing Assessment and Review Strategy] team visit. The AIB [Administrative Investigative Board] established that the subject dentist repeatedly violated infection control standards over a multiyear period."
The inspector general's office also confirmed that staffing levels in the dental clinic were suboptimal, which may have increased the likelihood that deviations from approved infection control practices would occur, and that interpersonal relations among dental clinic staff were, at times, "strained and negatively impacted the dental clinic," the report stated.
The report was released the day before the U.S. Senate Committee on Veterans' Affairs planned to hold a hearing on the matter. U.S. Sen. Sherrod Brown (D-OH) and U.S. Rep. Mike Turner (R-OH) have been pressing for information since the allegations against Dr. Pemberton were first disclosed.
"This report documents a leadership failure at the Dayton VA Medical Center. However, this report is limited in its scope, since it only includes testimony from those still employed by the VA or those who agreed to speak on the record," Turner said in a statement. "As a result, we have also learned that those who should be held accountable, including the dentist in question and hospital leadership have escaped scrutiny by simply retiring. In total, this report paints the picture of a system broken from the ground up. The culture at the VA needs to be changed to promote accountability for actions on the part of staff."
In February 2011, the VA notified 535 veterans that they may have been exposed to hepatitis B, hepatitis C, and HIV by Dr. Pemberton between 1992 and 2010. Of these, 507 have been tested; two patients tested positive for new cases of hepatitis B, and one patient tested positive for hepatitis C. There have been no new cases of HIV identified in the 535 patients, according to the VA.
Dr. Pemberton, who is 81, retired from the VAMC in February of this year.