Healthcare Inspection - Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY

The VA Office of Inspector General (OIG) conducted an inspection to assess the merit of an allegation made by a complainant concerning quality of care of a patient on a telemetry unit at the Manhattan Campus, New York Harbor Healthcare System. We did not substantiate that a telemetry equipment malfunction contributed to the patient’s death. We found that the telemetry equipment was functioning properly and that biomedical engineering personnel conducted preventive maintenance in accordance with the manufacturer’s specifications. We substantiated that staff on the telemetry unit failed to respond to a patient’s disconnected telemetry lead in a timely manner; as a result, the patient’s telemetry status was not effectively monitored at the time of his death. During the inspection we reviewed progress on corrective actions taken to address deficiencies related to a prior incident addressed by the OIG in an October 2011 report. Regarding both incidents, facility management had developed and initiated a comprehensive corrective action plan to address all deficiencies identified by internal review and the previous OIG inspection. We concluded that managers have made significant progress in all elements of the corrective action plan. We made no recommendations.