Department of Veterans Affairs surgeons accidentally embedded a piece of plastic tubing in a veteran’s leg, which later had to be amputated.

Memphis VA physicians were supposed to repair the blood vessels of a veteran suffering from diabetes and poor circulation in 2016, but instead they stuck 10 inches of plastic tubing in his leg, USA Today reports.

Doctors only discovered the mistake three weeks later when they amputated the veteran’s leg and found 3 inches of the tubing as they made incisions. Later, once the leg was fully cut off, they dug in and found the other 7 inches of tubing.

Internal documents from the Memphis VA show that this surgical disaster is just one out of many other issues plaguing the hospital. According to the VA’s own rating system, the Memphis VA scores just one out of five stars for quality.

The number of patient safety issues rose to 1,000 in 2016. The previous year the number was only 700.

The VA stepped in to remove managers and give the facility a new director as of May.

“When we determine facilities need extra attention — such as those in Memphis and Marion, Ill. — they are receiving it,” VA Press Secretary Curt Cashour told USA Today. “And we are not hesitating to take swift accountability actions when warranted.”

GOP Rep. Phil Roe, chairman of the House Committee on Veterans Affairs, said in a statement that the committee has been looking into the hospital since January.

“I’m disappointed and outraged by the many failures at the Memphis VA medical center, particularly the allegations regarding patient safety,” Roe said. “This is unacceptable, plain and simple.”

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