Healthcare Inspection – Quality of Care Issues Edward Hines, Jr. VA Hospital

OIG conducted an inspection at the Edward Hines Jr. VA Hospital, Hines, Illinois, at the request of the Chicago OIG Office of Criminal Investigations Division (CID). The purpose of the investigation was to determine if substandard quality of care contributed to the self-extubation and subsequent death of a veteran. The medical and surgical intensive care units, and Respiratory Care Services Department managers have implemented policies and procedures that establish responsibility and accountability for verifying and documenting all alarms related to patient safety and monitoring are functional. Additionally, Respiratory Care Services Department managers implemented policies and procedures to verify and document the security of the endotracheal tube on all patients receiving ventilator-assisted mechanical respirations. While the Biomedical Engineering Department installed metal cages to prevent disabling telemetry alarms at the central nurses’ station in the medical and surgical intensive care units, the design of the cages did not prevent disabling the alarms. We recommended reporting the incident to the VA National Center for Patient Safety, Biomedical Engineering Department reduce the width and length of the access opening on the metal cages surrounding telemetry alarms, and that managers ensure all nursing personnel are knowledgeable of the new policies and procedures. The VISN and Facility Directors agreed with the findings and recommendations.