A federal agency that protects government whistleblowers criticized the Army on Monday for declining to discipline a staff member at its Fort Bragg, North Carolina, hospital after an investigation found failures in infection control that put service members and families at risk.

Whistleblower Teresa Gilbert was a board-certified infection control technician at Womack Army Medical Center who reported violations of infection control policies in early 2014 that she said presented a health and safety threat to troops and family members at the hospital.

She reported that Womack staff members failed to correct infection control deficiencies that an earlier inspection had found, including dirty and unsterilized medical equipment, according to a redacted 2017 report by the U.S. Office of Special Counsel, the independent federal agency tasked with safeguarding whistleblowers from reprisal.

A supervisor retaliated against Gilbert by restricting her access to infection control practices and patient medical records and excluding her from meetings, the OSC report said. The supervisor also cut her work hours to half days, requiring her to take four hours of leave each day and then charging her with being absent without leave for not submitting leave requests for that time, the OSC report said. In addition, Gilbert was threatened that she would be removed from the hospital unit.

Gilbert took her concerns to management officials, the Office of the Inspector General and the Joint Commission, an independent agency that accredits hospitals and investigates complaints about them.

After an investigation of Gilbert’s disclosures, OSC urged the Army to discipline her first-line supervisor for taking part in personnel actions that are prohibited.

OSC expressed “alarm” in its release Monday that the Army didn’t follow up on its recommendation to discipline the supervisor, noting that its investigation found a pattern of retaliatory personnel actions against Gilbert.

But the Army previously said it had “settled all claims related to this matter,” according to the release.

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The Army wrote to OSC that it “acknowledges that certain actions in this case did not conform to Army standards and best practices. That is why the Army has already settled all claims related to this matter with Ms. Gilbert,” according to the Monday release.

Gilbert’s disclosures led to the Joint Commission visiting the hospital within months, and the visitors found a number of deficiencies, including failures to manage safety and security risks.

“Ms. Gilbert’s disclosures led to improvements that likely saved the lives of soldiers at one of the Army’s largest hospitals,” Special Counsel Henry Kerner said in the OSC release. “Her bravery deserves full justice, not partial measures. That includes achieving accountability from those directly involved in trying to shut her out. I urge the Army to reconsider its findings exonerating Ms. Gilbert’s supervisor from whistleblower retaliation and take appropriate disciplinary action.”

Because Gilbert’s supervisor was a service member, OSC has limited authority in taking disciplinary actions against the supervisor. OSC can recommend action, but the Army has discretion about whether it will carry out any action against a service member.

OSC found that Gilbert’s disclosures were protected and that they were a significant motivating factor in the personnel actions against her, the report said.

The Army’s own investigation found the person who acted against Gilbert was unqualified for the position and that lack of qualification was the primary reason for the “extremely serious infection control failures uncovered by the investigations,” the OSC report said.

OSC found that a pattern of retaliatory personnel actions against Gilbert aggravated the seriousness of the hospital’s infection control problems and increased the risk to patients. Those actions were likely a deterrent to others who may be whistleblowers, the report said, and the supervisor deserved discipline for actions that violated personnel policy.

“By statute, the Army is required to provide OSC with a report of actions it takes or proposes against [redacted] within 60 days of receiving this report,” it states.

The Army and Gilbert reached a monetary settlement in her claim of reprisal in September 2015 for an undisclosed amount. The settlement also involved removing negative information from Gilbert’s employment records, and other provisions, according to an OSC statement in 2015.