Acting Tomah VA medical center director Victoria Brahm said in a press conference Tuesday that almost 600 veterans who received dental care may have been infected with HIV or hepatitis.

According to Brahm, the VA is notifying 592 veterans who had dental procedures from a particular dental provider that they can come to the medical center for free testing. If any veterans test positive for HIV or hepatitis, they can receive free treatment, WEAU 13 News reports.

The VA has already notified 54 veterans by phone about the problem. The rest will find out via letters. Brahm insisted the chance of infection was low.

What ended up happening is that this dentist decided to purposefully violate regulations by using his own equipment and then reusing it after attempting to clean it down.

“It was purposeful that he was violating VA regulations,” Brahm said Tuesday. “During all of the orientation, he used all of our equipment. He used it appropriately, so it was very purposeful from what we found in our investigation that he knew exactly what he was doing, and preferred to use his own equipment against procedure.”

This dentist continued reusing equipment for one year from October 2015 to October 2016. Finally, an assistant noticed what the dentist was up to and reported him.

Instead of being fired, that dentist has been reassigned to an administrative role, despite potentially exposing almost 600 veterans to HIV or hepatitis.

However, the VA did refer the matter to the inspector general to see if criminal charges could be warranted.

That dentist has remained unnamed.

“We have clear evidence that we are moving forward and the people that remain here are very vested and here for the mission of taking care of veterans,” Brahm said. “There are pockets of improvement that need to occur they still need to I’ll be honest, and we are aware of where they are and we are dealing with them as quickly as we can.”

The HIV/hepatitis exposure problem is the latest in a series of scandals that have plagued the Tomah VA, which in recent years suffered from over-prescription of very potent opioids to veterans from former Chief of Staff Dr. David Houlihan, who patients had nicknamed “the Candy Man.” In 2015, the director of the Tomah VA facility was fired after reports emerged of the prescription problem.

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