Patient died at VA hospital after alarm was ignored
By CHARLES ORNSTEIN AND TRACY WEBER | ProPublica | Published: May 15, 2012
Registered nurses at a Manhattan Veterans Affairs hospital failed to notice a patient had become disconnected from a cardiac monitor until after his heart had stopped and he could not be revived, according to a report Monday from the VA inspector general.
The incident from last June was the second such death at the hospital involving a patient connected to a monitor in a six-month period. The first, along with two earlier deaths at a Denver VA hospital, raised questions about nursing competency in the VA system, ProPublica reported last month.
The deaths also prompted a broader review of skills and training of VA nurses. Only half of 29 VA facilities surveyed by the inspector general in a recent report had adequately documented that their nurses had skills to perform their duties. Even though some nurses "did not demonstrate competency in one or more required skills," the government report stated, there was no evidence of retraining.
Monday’s report documents the June 2011 death of patient in his 80s at the Manhattan campus of the VA’s New York Harbor Healthcare System. The man had undergone several heart procedures and needed to have his vital signs continuously monitored, the report said.
On his fifth day at the hospital, monitor records show that an alarm indicated a problem with the device or the patient. But there is no evidence nurses were aware of the alarm until the man was discovered unresponsive an hour and a half later. He was declared dead shortly afterward, the report said.
“The patient’s telemetry status was not effectively monitored at the time of his death due to a lack of awareness of the disconnected lead,” inspectors concluded.
Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes.
Ironically, federal inspectors were in the hospital the same month to investigate the first death, which occurred in a different monitoring unit in January 2011.
During that investigation, the inspectors discovered nurses at the hospital didn't understand how the monitors even worked. None of those interviewed could accurately explain what would happen if a patient became disconnected from a cardiac monitor.
Inspectors also found no evidence that the nurses' competence had been checked. Records showed that one of the patient's nurses had last received training on the monitors 13 years earlier, according the October 2011. The report recommended sweeping changes and retraining, which the hospital agreed to implement.
IG inspectors were not notified of the second death at the Manhattan facility until someone complained in November 2011, five months after the alarm was missed and the patient died.
The latest report does not recommend any additional changes or training at the hospital because “managers have made significant progress” after the first report.
In a response to the inspector general, the hospital acknowledged receipt of the report and said it concurred with the document. A spokeswoman for the VA in Washington didn’t immediately respond to our requests for comment.