The dental clinic came under scrutiny last July, when two employees alerted inspectors to clinic dentist Dr. Dwight Pemberton. A subsequent VA investigation found Pemberton failed to change gloves and sterilize dental instruments between patients for more than 18 years, from January 1992 to July 2010. Pemberton, 81, retired in February. Two patients seen by Pemberton have confirmed cases of hepatitis B and a third patient has hepatitis C that may have been contracted at the dental clinic.
The 24-page review placed some blame for the dental clinic’s problems at the feet of the Dayton VA’s leaders. So did U.S. Rep. Mike Turner, R-Centerville, who said the clinic suffered from a “lack of leadership.”
“In total, this report paints the picture of a system broken from the ground up,” Turner said in a prepared statement. He called for wider screening of clinic patients.
The review noted the dental clinic, which sees more than 3,000 patients annually, should have had more dental assistants. The lack of additional assistants may have increased the likelihood approved infection control practices were not followed, the report concluded. At the time inspectors were alerted to Pemberton’s infection control lapses, there were seven dentists and seven dental assistants.
“Efforts by the current chief of dental service to recruit and fill vacant dental assistant positions were not fully supported by the medical center with necessary funding, even though the chief of dental service cited an impact on safety and infection control issues,” the report said.
“The report confirms the known information from previous investigations, and it will allow the staff at the Dayton VAMC to continue moving forward with their service to our Veterans,” said Acting Medical Center Director William Montague.
On June 29 — less than one month before dental lab technicians Ray and Sherry Perdue of Fairborn alerted VA inspectors to Pemberton — a clinic dentist emailed the chief of dental service, expressing concern about Pemberton’s infection control practices.
In the June 29 email, the dentist claimed Pemberton would not clean his work space after seeing patients, then would boast he “worked without an assistant.”
The email also alleged Pemberton put his bare hands in a patient’s mouth, and answered his cell phone with gloves on his hands, then put those gloves back in a patient’s mouth without changing gloves or cleaning the phone.
The review also found relationships among dental clinic staff were strained and negatively affected the clinic.
Both the chief of dental service, Dr. Andrew Mesaros, and the clinic’s dental administrative officer, Josunde B. Collins, are facing disciplinary action. Mesaros has declined comment, and Collins could not be reached for comment Monday.
The OIG review offered two general recommendations, which Montague said will be completed by June, to the regional VA director in Cincinnati:
- Review the dental clinic findings, including staffing issues, and take "whatever action deemed appropriate";
- Ensure the Dayton VA Medical Center's director requires the dental service to comply with relevant infection control policies.
The inspector general’s office completed the review at the request of Congress.
Contact this reporter at (937) 225-7457 or bsutherly@DaytonDailyNews.com.
About the Author