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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Report Number
23-03531-218
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and placed a communication device on “DO NOT DISTURB” for long periods. The OIG identified an additional MIT (MIT B) who possibly engaged in similar practices.The OIG found that while monitoring a telemetry patient (Patient A), MIT A failed to document notifying nursing staff of Patient A's oxygen desaturation alarms (patient event A) and a registered nurse failed to document a change in Patient A’s condition after staff found Patient A unresponsive and pulseless. Further, the OIG found another patient (Patient B) reported experiencing cardiac symptoms (patient event B) to nursing staff. There was a delayed notification of the event to nursing staff due to reports that MIT B turned off the audio of patient B’s monitoring alarms.The OIG found that telemetry nursing leaders failed to ensure and document MITs adherence to clinical alarm monitoring expectations.The OIG found that facility staff did not enter a patient safety report in the Joint Patient Safety Reporting system for patient event A despite the event involving a patient death. Although a patient safety report was entered for patient event B, a patient safety manager rejected the event, which inhibited further investigation by patient safety staff.The OIG found the Associate Director Patient Care Services failed to provide oversight of clinical alarm management, which could result in an increased risk for the occurrence of patient safety events.The OIG made six recommendations to the Facility Director related to medical record documentation, review of the telemetry program, patient safety event reporting, institutional disclosure, and clinical alarm management.

Report Type
Inspection / Evaluation
Location

Aurora, CO
United States

Number of Recommendations
0
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 4 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The VA Eastern Colorado Health Care System Director evaluates and ensures that telemetry medical instrument technicians and registered nurses comply with Veterans Health Administration and facility policy requirements for documentation and scanning, specifically related to telemetry oxygenation and rhythm strips and change in patient condition.

02 No $0 $0

The VA Eastern Colorado Health Care System Director in conjunction with telemetry nursing leaders, ensures completion of a comprehensive review of the telemetry program and documented oversight of compliance with medical instrument technician monitoring expectations, identifies deficiencies, and takes actions as warranted

04 No $0 $0

The VA Eastern Colorado Health Care System Director evaluates and ensures quality and patient safety event review processes comply with Veterans Health Administration guidance, specifically regarding rejection and follow-up of patient safety reports.

05 No $0 $0

The VA Eastern Colorado Health Care System Director and facility leaders meet all Veterans Health Administration requirements for institutional disclosures for events meeting institutional disclosure criteria.

Department of Veterans Affairs OIG

United States