Healthcare Inspection Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver, Colorado
January 21, 2010
The purpose of this review was to determine the validity of allegations regarding inadequate telemetry heart monitoring practices and lack of staff training that related to two patient deaths. We concluded that both patients had multiple medical problems that contributed to their deaths, and it would be difficult to determine whether delays in response to abnormal cardiac rhythms led to their demise. We did not substantiate the allegation that the deaths were a result of inadequate telemetry monitoring or lack of staff training. We substantiated the allegation that management had been informed of problems with the telemetry program prior to the patient deaths and had not identified a clear course of action or assigned responsibility to address concerns raised. We substantiated the allegation that there were competency and training issues with medical support assistants and registered nurses assigned to telemetry. Temporary measures were enacted to ensure safe patient care following the first patient’s death. Managers concurred with our recommendations to evaluate the telemetry program, require that all staff complete competency assessments and that training be provided as needed to maintain competency, and that there be clinical oversight of medical support assistants.