Department Of Veterans Affairs Office Of Inspector General-Books Pdf

Department of Veterans Affairs Office of Inspector General
28 Sep 2020 | 0 views | 0 downloads | 20 Pages | 230.03 KB

Share Pdf : Department Of Veterans Affairs Office Of Inspector General

Download and Preview : Department Of Veterans Affairs Office Of Inspector General

Report CopyRight/DMCA Form For : Department Of Veterans Affairs Office Of Inspector General



Transcription

To Report Suspected Wrongdoing in VA Programs and Operations. Telephone 1 800 488 8244 between 8 30AM and 4PM Eastern Time. Monday through Friday excluding Federal holidays, E Mail vaoighotline va gov. Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver Colorado. Executive Summary, 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 at the VA Eastern Colorado Health Care System the system Denver. Colorado The complainant specifically alleged that despite notifying system. management of concerns regarding the telemetry program including incompetency and. lack of training of telemetry staff no action was taken to improve processes until patient. deaths occurred Our report addresses the complainant s allegations regarding processes. at the time of the patients 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 However. delays in notification of abnormal cardiac rhythms and in physical assessment could. make a difference for other patients, We substantiated the allegation that management had been informed of problems with the. telemetry program prior to the death of the first patient Memorandums and electronic. messages dated as early as July 2007 demonstrate that concerns were brought forward to. nursing management While nursing management acknowledged suggestions made in. the messages they received there was no clear course of action assigned to address. concerns raised in these messages, We substantiated the allegation that there were competency and training issues with.
medical support assistants and registered nurses assigned to telemetry prior to the death. of the first patient Although telemetry staff had initial telemetry training there was no. formal process to assess ongoing competency until after the Root Cause Analysis RCA. was conducted following the death of the first patient Medical support assistants that. performed telemetry monitoring did not have appropriate clinical supervision. At the time of our site visit the system was in the process of implementing changes based. on recommendations from the RCAs they had conducted regarding the two patients. Temporary measures were enacted to ensure safe patient care following the first patient s. death The VISN had been actively involved in monitoring the system s progress in. implementing changes following their receipt of the first RCA report. The VISN and System Directors concurred with our recommendations to evaluate the. telemetry program in its entirety require that all staff complete competency assessments. for their specific positions and that training be provided as needed to maintain. competency and that there be clinical oversight of medical support assistants. VA Office of Inspector General i, DEPARTMENT OF VETERANS AFFAIRS. Office of Inspector General, Washington DC 20420, TO Director VA Rocky Mountain Network 10N19. SUBJECT Healthcare Inspection Telemetry Monitoring Issues VA Eastern. Colorado Health Care System Denver Colorado, The VA Office of Inspector General OIG Office of Healthcare Inspections conducted. an inspection to determine the validity of allegations regarding inadequate telemetry heart. monitoring practices and lack of staff training that related to two patient deaths at the VA. Eastern Colorado Health Care System the system Denver Colorado. Background, The system is in the VA Rocky Mountain Network Veterans Integrated Service. Network VISN 19 The system provides comprehensive healthcare through primary. care tertiary care and long term care in the areas of medicine surgery psychiatry. physical medicine and rehabilitation neurology oncology dentistry geriatrics and. extended care It is affiliated with the medical pharmacy and nursing schools of the. University of Colorado Health Sciences Center Residency programs are maintained in. internal medicine surgery psychiatry neurology physical medicine and rehabilitation. anesthesia pathology radiology and dentistry, The OIG Hotline Division received a complaint that there have been two patient deaths.
related to the inadequacy of telemetry heart monitoring at the system The complainant. specifically alleged that despite notifying system management of concerns regarding the. telemetry program including incompetency and lack of training of telemetry staff no. action was taken to improve processes until patient deaths occurred The system. conducted Root Cause Analyses RCAs following the patient deaths and at the time of. our site visit was in the process of implementing changes based on the RCA. recommendations This report addresses the complainant s allegations regarding. processes at the time of the patients deaths and prior to the RCAs. The centralized telemetry monitoring station was located in the medical intensive care. unit MICU The actual telemetry beds were located on two units remotely located from. VA Office of Inspector General 1, Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver Colorado. the monitoring station Twelve telemetry beds were located on an acute care medical unit. in the process of expanding to 16 beds and 4 telemetry beds were located on a surgical. unit When the medical center changed their organizational structure from traditional. services to service lines in the late 1990s ward clerks received training that consisted of a. 3 day electrocardiogram EKG class Upon passing the required test at the end of the. class these ward clerks were reclassified from General Schedule GS grade 5 to medical. support assistants MSAs at a GS grade 6 In addition to ward clerk duties such as. answering telephones timekeeping maintaining medical records ordering supplies and. responding to patients and family members each qualified MSA served as a telemetry. technician Any newly hired MSA also completed the EKG training and test Telemetry. technicians maintained surveillance of the central monitoring station at all times There. is a ceiling for 28 full time MSAs with a current staff of 25 including 2 light duty. registered nurses RNs Two lead MSAs who report to an administrative supervisor. program specialist provide direct supervision The MSA positions are organizationally. structured under the Associate Director for Patient Care Services ADPS who is a RN. According to local policy MSAs are responsible for registering patients into the main. telemetry monitoring system and continuously monitoring the patient s cardiac rhythm. They are to ensure that parameter alarms are on when the patient is monitored and set the. ordered alarm rates If there are significant rate changes they are responsible for. notifying a RN on the unit where the patient is located There are telephones located on. the medical and surgical unit that are only used for communication from the central. telemetry monitoring station The charge RNs on the units are also required to carry. digital pagers, RNs on the two units are responsible for routine patient care for telemetry patients as. well as other medical surgical patients located there Their telemetry responsibilities. include placing cardiac leads on patients notifying telemetry MSAs if patients are. discontinued from monitoring for any period of time giving reports to the telemetry. MSAs on all new telemetry patients verifying rhythms and taking appropriate actions. and entering progress notes every shift at the times of any rhythm changes and upon. discontinuation of telemetry monitoring, Scope and Methodology. We interviewed the complainant by telephone to obtain clarification of the allegations. prior to our site visit We conducted a site visit at the system February 17 18 2009 and. interviewed system management MSAs supervisors quality management and other. staff We reviewed policies procedures training records directives electronic messages. quality management documents and medical records The clinical case reviews in this. report are abbreviated and limited to telemetry events System physicians addressed. specific clinical issues identified through peer reviews and RCAs were conducted for. both patient deaths, VA Office of Inspector General 2. Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver Colorado. We conducted the review in accordance with Quality Standards for Inspections published. by the President s Council on Integrity and Efficiency. Inspection Results, Clinical Case Reviews, The patient was a male in his seventies with a history of a liver transplant in 1990 a.
kidney transplant in 2003 and a major stroke with resulting partial paralysis in late April. 2008 He was transferred to the system from a private hospital the first week in May for. ongoing treatment related to his stroke On admission to the medical unit physicians. placed the patient on telemetry to monitor for arrhythmias specifically atrial fibrillation 1. Physicians wrote orders to notify them if the patient s heart rate was less than 60 beats. per minute Over the next few days the patient s heart rate ranged from 60 90 in a. normal sinus rhythm or atrial fibrillation The patient had complications related to his. stroke that required blood thinning medications for treatment On hospital day 5 a. physician s order changed the telemetry monitoring parameters to notify the physician for. a heart rate of 50 or lower, On hospital day 6 a nursing note documents that the patient was in atrial flutter 2 and an. EKG was completed The physician noted that the patient had been in and out of atrial. fibrillation and ordered continued telemetry monitoring. On hospital day 7 at 7 07 a m the patient had a low heart rate of 49 A telemetry MSA. called the medical unit to inform a RN of the low rate but according to notes from the. MSA no one answered the telephone At 7 08 a m the patient s heart rate had. decreased to 24 and was still dropping The MSA again called the medical unit and. informed the medical unit MSA who answered the telephone that the patient was having. bradycardia 3 The RN assigned to care for the patient was not in the immediate area so. the unit MSA went to find the RN and inform her of the change in heart rate By 7 10. a m the patient s heart rate was less than 20 when the telemetry MSA called the medical. unit again and spoke with an RN who answered the telephone According to progress. notes the RN immediately sent a licensed vocational nurse LVN to assess the patient. Progress notes document that a cardiac arrest code was called after the LVN assessed the. patient Telemetry monitoring strips document that at 7 13 a m the patient s heart did. not show any electrical activity and resuscitation was initiated at that time Following. Atrial fibrillation is an irregular heart rate that can cause inadequate blood circulation in the heart resulting in. pooling of blood and eventual clots that can lead to stroke. Atrial flutter is an abnormal heart rate arrhythmia similar to atrial fibrillation that occurs when electrical impulses. take an abnormal path through the upper chambers of the heart. Bradycardia is an abnormally slow heart rate normally defined as less than 60 beats per minute. VA Office of Inspector General 3, Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver Colorado. resuscitation efforts a pulse and blood pressure were obtained and the patient was. transferred to the MICU but was non responsive and on mechanical ventilation The. patient had to be resuscitated a second time in the MICU Physicians consulted with the. family and the patient was removed from mechanical ventilation at 1 52 p m and. pronounced dead at 1 57 p m There was no autopsy but the cause of death was. determined to be most likely from a retroperitoneal bleed 4. The patient was a male in his sixties admitted from the Emergency Department in the. first week of January 2009 for shortness of breath lower extremity swelling recent 10. pound weight gain and reduced urine output He had multiple medical problems that. included coronary artery disease with bypass surgery in 1998 aortic stenosis mitral. regurgitation chronic atrial fibrillation lung disease acute renal failure chronic renal. insufficiency and diabetes mellitus For the fist 4 days of hospitalization his clinical. treatment focused on diuresis and electrolyte management Both nephrology and. cardiology services were consulted regarding the patient s treatment. The patient had complained of nausea and vomiting for several days and had irregular. heart rhythms that were noted on daily telemetry monitoring strips On hospital day 7 at. 8 35 p m the telemetry MSA noted a 6 beat run of ventricular tachycardia and called the. unit RN After speaking with the MSA the unit RN attempted to page the medical. resident At 8 42 p m notes written on the telemetry monitoring strip state that the. telemetry MSA contacted the medical unit RN of additional episodes of irregular wide. complex rhythms At 8 43 p m telemetry monitoring strips further note that the patient. had continued runs of ventricular tachycardia and attempts were made to call the medical. Department of Veterans Affairs Office of Inspector General Healthcare Inspection Telemetry Monitoring Issues VA Eastern Colorado Health Care System Denver Colorado Report No 09 01047 69 January 21 2010 VA Office of Inspector General Washington DC 20420 To Report Suspected Wrongdoing in VA Programs and Operations Telephone 1 800 488 8244 between 8 30AM and 4PM Eastern Time

Related Books

VIVIR AL IMAGEN Y SEMEJANZA DE DIOS

VIVIR AL IMAGEN Y SEMEJANZA DE DIOS

reflexionar sobre la invitaci n de Jes s a vivir una vida digna de su llamado a la santidad Como pueblo llamado a la santidad nos damos cuenta de que esta vocaci n es en realidad una invitaci n a vivir una relaci n diaria con la persona de Jes s una llamada a la conversi n es decir a asemejarnos cada vez m s a la persona de Jesucristo 2 3 Introducci n C reemos que Dios cre

Ingresos que garanticen una vida digna

Ingresos que garanticen una vida digna

dignos para vivir Para Oxfam Interm n todas las personas tienen derecho a una vida digna sin pobreza ni exclusi n social y ello requiere tener cubiertas las necesidades b sicas Unas pol ticas sociales adaptadas al contexto socioecon mico y unos ingresos m nimos para cubrir estas necesidades son las claves para romper con el c rculo de desigualdad y pobreza Pese a que la seguridad

Condiciones para una vida digna Universidad Nacional De

Condiciones para una vida digna Universidad Nacional De

realizaci n de una vida digna a un n mero cada vez mayor de seres humanos debe estar presente en la formulaci n de las estrategias de desarrollo sostenible resumido en los principios de equidad igualdad de oportunidades para todos en la sociedad sostenibilidad responsabilidad con las generaciones futuras productividad aumento constante en la productividad siempre que no se

Move by Move 1b6 debestezet nl

Move by Move 1b6 debestezet nl

Move by Move is a series of opening books which uses a question and answer format One of our main aims of the series is to replicate as much as possible lessons between chess teachers and students All the way through readers will be challenged to answer searching questions and to complete exercises to test their skills in chess openings and indeed in other key aspects of the game

Red Comet AP English Literature amp Composition Prerequisites

Red Comet AP English Literature amp Composition Prerequisites

Red Comet AP English Literature amp Composition For a year participate in an AP upscale dining experience in the AP Literature and Composition course Students act as food critics of exquisite literary cuisine Menu items include reading analyzing writing rewriting and discussing creations by the master chefs renowned authors With intensive concentration on composition skills and on

Veterans Memorial Early College High School Senior English

Veterans Memorial Early College High School Senior English

Senior English Summer Reading Information 2018 Summer reading is an important part of the early college student s experience Current research suggests that summer reading helps students maintain important literacy skills and provides all students with a shared experience to build upon in when they return to school Below are the summer reading directions for all incoming senior students

AP English Literature and Composition Major Work Data

AP English Literature and Composition Major Work Data

Major Work Data Sheet a Title Oedipus Rex Author Sophocles Pub Date 430 B C Genre Tragedy Historical information about the literary era Oedipus Rex was written during the Classical Period of Ancient Greece The period consisted of numerous battles with the Persians Many of famous Greek works originated during this period of time The most renowned artists philosophers and

Brand yourself amp your club

Brand yourself amp your club

Don t crowd our wordmark Give it lots of space Call it K space Take the height of the letter K in whatever size you re using the wordmark and allow a K space all around the logo Primary use horizontal logo Stacked version Vertical options Height of the letter K Minimum wordmark print size 1 25 inches wide

Shepparton Textile Artists Inc present How to book A

Shepparton Textile Artists Inc present How to book A

2 Print a T Shirt 4 hr 35 Go home with a couple of T shirts printed with your own fun design You will learn how to do a small lino cut and then use stamping tools to print your lino cut onto a T shirt No previous skill required What to bring Lunch or buy from Eastbank cafe apron

DRAGONFLY DESIGNS AFTERSCHOOL PROGRAMS amp MOBILE CAMPS

DRAGONFLY DESIGNS AFTERSCHOOL PROGRAMS amp MOBILE CAMPS

DRAGONFLY DESIGNS AFTERSCHOOL PROGRAMS amp MOBILE CAMPS Questions amp Registration call text 650 303 1900 website www dragonflyfun com Since 2005 Dragonfly Designs has been sharing the joy of art and jewelry making with our community in the San Francisco Bay Area The aim of our family business is to enable children s creativity through holistic art education We believe that artistic

St Lawrence Martyr Fun Run

St Lawrence Martyr Fun Run

Print T shirt Receipt Order T shirts and print receipt by November 7th Submit receipt and payment to school office by November 15th Make check payable to SLM Fun Run Keep a copy of receipt for your records If you do not order additional T shirts you do not need to submit a receipt How to Order T shirts Click Pledges to enter pledges for each child Enter the number