Alleged Deficiencies within the Cardiac Telemetry Monitoring Service at the Nashville VA Medical Center in Tennessee

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication. The OIG did not substantiate • The system’s policy related to telemetry monitoring and practices was outdated, • Staffing shortages or inadequate training of staff performing telemetry monitoring, • Telemetry patients with “do not resuscitate” orders did not receive clinically appropriate interventions, or • Nursing staff had knowledge deficits related to the care of telemetry patients with do not resuscitate orders. However, there were identified isolated communication issues between telemetry technicians and telemetry patient nurses related to the specific location and movement of telemetry patients while in the hospital. The OIG did not make a recommendation since an electronic patient tracking system was available in case of an emergency. In addition, in 2018, facility leaders identified other telemetry communication issues. The OIG reviewed facility leaders’ actions and noted overall improvement since staff training in February 2019. Therefore, the OIG made no recommendation. The OIG identified improper reusable medical equipment practices with the return of used and contaminated telemetry boxes and the location of clean supplies. System leaders took immediate steps and the OIG determined that no further action was indicated. The OIG determined the rapid response team policy and staff practice regarding the initiation of a rapid response team call did not always align, which is important to mitigate system vulnerabilities. The OIG made one recommendation to the Tennessee Valley Healthcare System Director to ensure consistency between the system’s policy and actual practice for initiating a rapid response team call.