In one case, the VA OIG Office of Healthcare Inspections reviewed allegations of poor monitoring of a patient who died on the telemetry unit at the Manhattan Campus of the New York Harbor Healthcare System in New York, NY.
Inspectors found that "medical record documentation by unit staff did not meet industry or facility requirements and that telemetry unit nursing and biomedical engineering staff were not trained to properly use the telemetry monitoring equipment." Neither was there evidence of any refresher training.
The deficiencies were startling. Inspectors discovered that the many of the nurses they interviewed didn't know which alarms would sound if a telemetry lead became disconnected from a patient's chest; whether an ECG strip would automatically print if a lead became disconnected; how to set the parameters on the monitoring system; and or how to retrieve and print a patient's electronically saved telemetry history.
In addition to identifying the critical need for training and refresher courses, the April VA OIG report also cites the Joint Commission requirement that hospitals take action when staff competence does not meet expectations. Although the review found that 58 (17%) of 349 RNs did not demonstrate competency in one or more required skills, it didn't find documentation of actions taken to address the deficiencies for 41% of the 58 RNs.