Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas

OIG conducted an inspection in response to allegations that untrained employees monitor inpatients on telemetry (portable device that allows continuous observation of a patient’s heart rate and rhythm); that since January 2014, several inpatients on telemetry monitoring have died who potentially could have been saved if nursing staff were alerted rapidly to observed cardiac arrhythmias; and that the new telemetry monitoring equipment installed in February 2013 does not allow patient monitoring in a safe and effective way at the Michael E. DeBakey VA Medical Center, Houston, TX. We did not substantiate the allegation that untrained employees were monitoring inpatients who were on telemetry. We did not substantiate the allegation that patients on telemetry, during the period January 1, 2014, through July 18, 2014, died who potentially could have been saved if telemetry staff had notified nursing staff of observed cardiac arrhythmias. However, of the 40 telemetry patients with facility-conducted mortality reviews, we found documentation of 18 (45 percent) patients with a “hospice” or “comfort care status. We did not substantiate the allegation that the new telemetry monitoring equipment installed in February 2013 prevents patients on telemetry from being monitored in a safe and effective way. We did not find staff sleeping; however, we did find that some unit staff were not carrying the facility-required telephones used for direct communication between telemetry and unit staff. We revisited the same areas during the day shift and found staff on two of the same units not carrying the required telephones. We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed. We also recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.