Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Alleged Telemetry Unit Deficiencies
 

VA New York Harbor Healthcare System
 

New York, New York
 

Report No. 11-02545-15 October 27, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 

 


 


 


 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted a review 

to determine the validity of an allegation regarding the quality of patient care on a 

telemetry unit at the Manhattan Campus of the New York Harbor Healthcare System, 

New York, NY. Specifically, the complainant alleged that a patient on the telemetry unit 

was not continuously monitored and the telemetry monitoring system displayed a 

disconnected telemetry lead. The complainant expressed concern that poor staffing 

and/or an equipment malfunction may have contributed to a lack of monitoring and the 

patient’s death. 

We could neither confirm nor refute the allegation that a patient on the telemetry unit was 

not continuously monitored due to a disconnected telemetry lead, malfunctioning 

monitoring equipment, or short staffing. The unit did not maintain sufficient 

documentation for us to determine if a telemetry lead became disconnected on the patient. 

We found that the telemetry equipment was functioning properly and that preventive 

maintenance was conducted in accordance with the manufacturer’s specifications. 

Staffing on the night in question was consistent with the patient-to-nurse ratio that the 

system described as their usual practice based on industry standards. 

However, our review did find that the unit had two system weaknesses that increased the 

risk of patients not being adequately monitored. Specifically, we 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. 

To improve patient care and safety for telemetry patients, we recommended that the 

facility Director: 

	 Implement procedures to ensure that telemetry unit nursing staff comply with 

industry standards and system policies on charting and telemetry documentation to 

maintain a timely, complete, and accurate medical record for each patient. 

	 Ensure that telemetry unit nursing and biomedical engineering staff receive initial 

and refresher training on the telemetry monitoring system in accordance with 

Veterans Health Administration and facility policies. 

The Veterans Integrated Service Network and Medical Center Directors concurred with 

the findings and recommendations and provided an acceptable action plan. We will 

follow up on the planned actions until they are completed. 

VA Office of Inspector General i 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Director, VA New York Harbor Healthcare System (630/00) 

SUBJECT: Healthcare Inspection—Alleged Telemetry Unit Deficiencies, VA New 

York Harbor Healthcare System, New York, New York 

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted 

an inspection to assess the merit of an allegation made by a complainant concerning 

quality of care for a patient in a telemetry unit at the Manhattan Campus, New York 

Harbor Healthcare System (the facility), New York, NY. 

Background

VA New York Harbor Healthcare System

The facility is part of Veterans Integrated Service Network (VISN) 3 and comprises three 

campuses located in Manhattan, Brooklyn, and Queens. The Manhattan Campus has bed 

services in acute medicine, surgery, acute psychiatry, neurology, and rehabilitation 

medicine. The campus is the VISN 3 referral center for interventional cardiology, 

cardiac surgery, and neurosurgery. 

The telemetry unit (the unit) is a 19-bed step down unit located in the main hospital at the 

Manhattan Campus. Patients who are hemodynamically stable1 but still require 

continuous electrocardiogram (ECG) monitoring are admitted to the unit, including 

patients who have been transferred from the medical intensive care unit (MICU) and the 

cardiac care unit (CCU). 

Allegation

In April 2011, a complainant contacted the OIG’s Hotline Division and alleged that in 

January 2011, a patient on the telemetry unit was not continuously monitored and that, 

according to a registered nurse (RN), the telemetry monitoring system displayed a 

disconnected telemetry lead. The complainant expressed concern that poor staffing 

1 Hemodynamically stable indicates that the circulatory system is functioning well enough to provide adequate blood 

flow throughout the body. 

VA Office of Inspector General 1 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

and/or an equipment malfunction may have contributed to a lack of monitoring and the 

patient’s death. 

Overview of Telemetry Monitoring for Cardiac Patients

Telemetry monitoring provides a continuous ECG reading of the heart’s electrical 

activity through external electrodes placed on the patient’s body. Segments of the ECG 

data are automatically transmitted to a remote surveillance location. As the patient’s 

electrical rhythms are transmitted, they are continuously analyzed according to 

parameters programmed into the device. Some segments, such as rapid and slow heart 

rates or other symptomatic episodes, will automatically trigger an audible alarm. 

Hospital staff who acknowledge the alarms and observe the telemetry data are able to 

respond to the patient and provide immediate care should emergencies arise. The 

telemetry monitoring equipment at the system triggers three types of audible alarms: 

	 Red Alarm is an audible critical alarm that is loud and continuous. It indicates 

the need to immediately check on a patient’s status and vital signs. 

	 Yellow Alarm is a quieter and intermittent audible alarm that stops after several 

minutes. It indicates a temporary irregularity in the heart rate or rhythm that is not 

immediately critical. 

	 Blue Alarm is similar to the yellow alarm and indicates a problem with the system 

itself or an improperly connected, or disconnected, telemetry lead. 

Facility Policy and Industry Standards

According to the facility protocol for telemetry monitoring, all telemetry unit patients 

must be hemodynamically stable.2 Unstable patients and those with Acute Coronary 

Syndrome3 should be managed in an intensive care unit. The protocol also identifies 

criteria for initiating telemetry monitoring on patients with various cardiac conditions. In 

this case, the patient required monitoring of his heart rate because of atrial fibrillation 

with rapid ventricular response4 but did not have chest pain. 

According to the protocol, RNs on the unit are required to perform the following 

telemetry monitoring and documentation procedures: 

2 New York Harbor Healthcare System (NYHHS) Policy No. 111-05, Electrocardiographic Telemetry Monitoring
 

Protocol, November 2008.
 3 Acute Coronary Syndrome is when the heart does not receive enough oxygen-rich blood, which can cause chest
 

pain or a heart attack.

4 Atrial fibrillation with rapid ventricular response is an irregular heart rate that can cause inadequate blood
 

circulation through the heart, resulting in pooling of blood and eventual clots that can lead to stroke.
 

VA Office of Inspector General 2 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

	 Connect the patient to the telemetry monitor using a modified central lead-15 or a 

lead that best transmits the appropriate waveform. 

	 Set alarm parameters according to the individual patient’s needs and/or the 

physician’s specifications, and ensure that the alarm volume is loud enough to be 

heard at all times. 

	 Keep alarms on at all times. 

	 Obtain and attach a representative sample of ECG strips to the hard copy medical 

record every shift and when necessary to document any abnormality and 

interventions instituted. 

	 Report any abnormalities to the physician. 

	 Review the alarms each hour. 

	 Respond immediately to alarm activation, institute appropriate intervention, and 

notify the physician. 

Standards published by the American Heart Association (AHA) advocate that each 

facility establish protocols to govern the roles and responsibilities at all staff levels 

regarding cardiac monitoring, documentation of ECG changes, periodic documentation 

that alarms are set appropriately, and response to emergency and nonemergency cardiac 

events.6 

The AHA recommends that all staff assigned to telemetry units receive comprehensive 

training, including initial orientation followed by periodic competency evaluations, to 

ensure continued proficiency in critical elements of cardiac monitoring. AHA also 

recommends periodic reviews of unit protocols, training curricula, and competency levels 

to determine if staff and patient needs continue to be met. This analysis should include 

reviews of staff performance, critical events, and patient outcomes. 

Scope and Methodology

We conducted a site visit from June 14 through 16, 2011. To address the allegation, we 

interviewed the complainant, staff physicians, the unit supervisor and nursing personnel, 

and other clinical and administrative staff. We reviewed relevant facility policies and 

procedures, nurse training records, preventive maintenance reports, quality management 

documents, and the medical record of the patient identified in the complaint. We visited 

the unit, the MICU, and the CCU and reviewed the functions of the telemetry equipment 

with nursing staff and a member of the biomedical engineering staff. 

5 A modified central lead-1 is the primary lead on a 3-lead telemetry monitoring system that is attached to the
 

patient.

6 AHA Scientific Statement, Practice Standards for Electrocardiographic Monitoring in Hospital Settings,
 

American Heart Association Science Advisory and Coordinating Committee, June 2004.
 

VA Office of Inspector General 3 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of Inspectors General on Integrity and Efficiency. 

Case Summary

The patient was a man in his sixties with a history of 2-vessel coronary artery bypass 

graft surgery7 and mitral valve8 repair in 2007, high blood pressure, and atrial fibrillation. 

He presented to the emergency department in mid-January, 2011, with a chief complaint 

of shortness of breath on exertion for a duration of 2 weeks accompanied by weakness 

and fatigue. The emergency department admission assessment note indicated that the 

patient was oriented and denied any chest pain. His blood pressure was elevated, and the 

ECG showed the patient to be experiencing supraventricular tachycardia with a rapid 

ventricular response (endorsed as atrial flutter9 by a staff cardiologist’s ECG report). The 

patient was treated with cardiac medications for ventricular rate control and transferred to 

the MICU for further management and monitoring. 

The plan of care included monitoring of vital signs every 8 hours and heart rate and 

rhythm every hour. MICU nursing staff were to monitor vital signs and urine output, 

achieve full anticoagulation, continue outpatient medications, and institute cardiac 

monitoring (for ongoing assessment of heart rate control). Within 24 hours, (hospital day 

[HD] 2) the patient’s heart rate was effectively rate controlled in the MICU. The MICU 

nursing progress note indicated no additional changes in the plan of care, and the patient 

was transferred at 7:30 p.m. to the CCU. Patients are transferred to the CCU, an area 

immediately adjacent to the MICU, when they still require close monitoring but at a less 

intense level than the MICU. A CCU physician’s team note, written that same day, 

specified the plan of care was to schedule a cardiac ablation10 for the upcoming week in 

an attempt to more effectively control heart rate and to keep the patient in the hospital in 

the interim for ongoing anticoagulation, blood pressure control, monitoring, and 

observation. 

On HD 3, the patient remained asymptomatic and was acceptably controlled as to heart 

rate. A resident physician ambulated the patient at 6:00 p.m., and, being clinically stable, 

the patient was transferred from the CCU to the telemetry unit, though he did have 

persisting significant blood pressure elevation. 

The telemetry unit’s nursing acceptance note documents the patient as arriving via 

wheelchair at 6:15 p.m. and being placed on a cardiac monitor showing him to be in 

7 Coronary artery bypass graft surgery is a procedure to improve blood flow to heart tissue; it is most commonly
 

performed by grafting a section of vein material to bypass an obstruction or narrowing of a coronary artery.

8 The mitral valve controls blood flow between the left upper and lower chambers of the heart.
 9 Atrial flutter is a type of supraventricular tachycardia where the upper chambers of the heart beat abnormally fast
 

and, when accompanied by a rapid ventricular response, the lower chambers also beat abnormally fast.

10 Cardiac ablation is a type of treatment for cardiac arrhythmias.
 

VA Office of Inspector General 4 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

normal sinus rhythm11 with occasional premature ventricular contractions,12 a heart rate 

of 95 beats per minute, and persistent elevated blood pressure. The patient was also 

noted to be alert and oriented, having no chest pain, and ambulating independently. The 

plan of care was to include monitoring of vital signs every 8 hours and heart rate and 

rhythm every hour. A medicine resident physician’s examination in the telemetry unit at 

7:15 p.m. indicated the patient to be acceptably heart-rate controlled but with continuing 

high blood pressure readings (“uncontrolled at baseline”), and the physician’s note 

expressed the intent to continue blood pressure control, anticoagulation, and plans for a 

“possible ablation” on HD 7. 

At 7:30 p.m. on HD 3, the patient’s nursing care was assumed by a new shift of nurses on 

the telemetry unit. The first chart entry made by the telemetry unit RN who had assumed 

responsibility for the patient at 7:30 p.m. was a transfer summary completed at 4:33 a.m. 

on HD 4, an hour after the patient was found unresponsive (that is, no nursing chart 

entries were made during the first 9 hours on this particular telemetry unit nursing shift). 

The transfer summary included retrospective entries regarding the patient’s condition 

from the previous evening. The note cited the patient as being on the telemetry monitor 

with normal sinus rhythm and a heart rate of 80 beats per minute as of 7:30 p.m. on HD 

3. In addition, the note documented that the patient received his scheduled cardiac 

medication at 11:24 p.m. and had denied chest pain, dizziness, palpitations, or shortness 

of breath. The note chronicles that at 3:35 a.m. on HD 4, the patient was found 

unresponsive with no palpable pulse and with a blood pressure of 64/40 mmHg. At that 

time, staff initiated cardiopulmonary resuscitative measures and called a cardiac arrest 

response team to the unit. 

Following resuscitative efforts, the patient was restored to a sinus bradycardia rhythm13 

but with evidence of severe brain injury resulting from the cardiac arrest, as confirmed by 

a neurology resident physician. The patient was transferred back to the MICU at 

4:45 a.m. on HD 4 and required ventilator support. 

The period of unresponsiveness prior to the code is not determinable based on the limited 

nursing note documentation and the lack of telemetry data prior to the code. The 

patient’s post-resuscitative severe brain injury, though, was associated with a poor 

prognosis and high mortality. According to an MICU nursing progress note, later on HD 

4, the patient experienced a rapid drop in his blood pressure and heart rate, and a cardiac 

arrest response team was called at 2:15 p.m. Resuscitative efforts were unsuccessful, and 

the patient was pronounced dead at 2:35 p.m. on HD 4. 

11 Sinus rhythm is the normal beating of the heart as measured by an ECG.
 12 Premature ventricular contractions occur when the heartbeat is initiated by a site in the heart’s lower chambers
 

rather than its normal initiation site in the sinus node.
 13 A sinus bradycardia rhythm is a regular but slow heart rate beating 60 beats a minute or less.
 

VA Office of Inspector General 5 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Inspection Results

We could neither confirm nor refute the allegation that in mid-January 2011, a patient on 

the telemetry unit was not continuously monitored due to a disconnected telemetry lead, 

malfunctioning monitoring equipment, or short staffing. 

Disconnected Telemetry Lead. The telemetry unit did not maintain sufficient 

documentation for us to determine if a telemetry lead became disconnected on the patient. 

According to the patient’s medical record, he was transferred from the CCU to the 

telemetry unit on HD 3 at 6:15 p.m. and placed on a telemetry monitor. A nursing 

transfer note written by an MICU RN at 4:45 a.m. on HD 4, after the patient was 

transferred back to the MICU, indicates that on HD 3, a telemetry RN checked on the 

patient at 7:30 p.m. According to the note, the patient was on the telemetry monitor at 

7:31 p.m., which is supported by a unit report generated by the telemetry monitoring 

system. 

We found no additional documentation in the patient’s medical record, such as nurse 

progress notes or copies of telemetry monitor print-outs, or in unit monitoring records to 

verify if the patient continued to be on the telemetry monitor. We did find a telemetry 

observation record for HD 4, which indicated that nursing staff reviewed telemetry 

monitor alarms every hour. However, the telemetry observation record was not patient 

specific and did not reflect if any alarms had occurred. Furthermore, facility staff could 

not provide us this record for HD 3. 

Malfunctioning Equipment. During our discussion with the complainant, the 

complainant referenced an ECG report in the patient’s medical record indicating poor 

data quality, which may affect interpretation. The complainant expressed concern that 

this indicated some type of malfunction with the telemetry monitoring equipment. Based 

on our inspection of the equipment with a facility biomedical engineer and our review of 

applicable biomedical engineering records, we found that the equipment was functioning 

properly and that preventive maintenance was conducted in accordance with the 

manufacturer’s specifications. We also found that an ECG was performed on the patient 

after the cardiac arrest on HD 4. Although the ECG report did indicate poor data quality, 

this is an indication that the equipment is functioning properly and informs the user that 

there is a presence of an artifactual signal, such as electrical interference from wall 

outlets, cell phones, muscle tremors, or patient movement.14 The presence of artifactual 

signal was not a significant finding in this case and did not, in any way, affect the 

patient’s clinical outcome. 

Short Staffing. According to facility nurse managers, the telemetry unit should have a 

patient-to-RN staffing ratio of 5:1. Although the facility does not have a policy explicitly 

requiring this staffing, the nurse managers told us that it is consistent with guidance from 

14 Artifactual signal is anything on an ECG that is not caused by the electrical currents generated by the heart. 

VA Office of Inspector General 6 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

the American Nurses Association.15 On the night of January HD 3, there were nine 

patients on the telemetry unit, and staffing included two RNs from 7:30 p.m. to 8:00 a.m., 

a third RN from 12:00 a.m. to 8:00 a.m., and one nurse's aide from 3:30 p.m. to 12:00 

a.m. Therefore, the patient-to-RN staffing ratio of 3:1 was well within the target ratio of 

5:1. 

Although we could neither confirm nor refute the allegation that the patient was not 

continuously monitored during his hospitalization in January, our review did find that the 

unit had two system weaknesses that increased the risk of patients not being adequately 

monitored. Specifically, we found that medical record documentation by unit staff did 

not meet The Joint Commission or facility requirements and that telemetry unit nursing 

and biomedical engineering staff were not trained to properly use the monitoring 

equipment. 

Medical Record Documentation Did Not Meet Requirements

JC requires that a complete and accurate medical record be maintained for each patient.16 

Facility policy requires an RN to print out an ECG strip every shift and to evaluate each 

alarm printout. The RN is also required to document any abnormal rhythms, provide a 

rapid response to each alarm, and review all alarms every hour.17 

We found that patient care documentation lacked sufficient detail to verify whether 

patients were continuously monitored while on the unit. We found significant time gaps 

in nursing documentation in the subject patient’s medical record. For example, the 

record contained a telemetry unit admission note for HD 3 at 6:15 p.m.; however, no 

further nursing notes were documented by a telemetry unit RN until 4:33 a.m. on HD 4, 

after the patient had been transferred back to the MICU. Furthermore, we did not find 

any ECG strips in the patient’s medical record from the time he entered the unit on HD 3 

at 7:30 p.m. to the time he was found unresponsive on HD 4 at 3:35 a.m. 

According to telemetry unit staff, they also use unit-wide records to document patient 

observations and reviews of telemetry monitor alarms. Documentation of these records is 

for all patients on the unit and is not included in individual patient medical records. For 

example, we reviewed a unit report for HD 3, indicating that all patients on the unit were 

on telemetry monitors at 7:31 p.m. We also reviewed a telemetry observation record for 

HD 4, indicating that nursing staff reviewed telemetry monitor alarms every hour, as 

indicated by a check mark. However, as previously discussed, this telemetry observation 

record was not patient specific and did not reflect whether any alarms had occurred. 

Furthermore, we found that unit staff did not retain these unit records in a structured 

15 Utilization Guide for the American Nurses Association Principles for Nurse Staffing, 2005.
 16 Joint Commission, RC 01.01.01: The hospital maintains complete and accurate medical records for each
 

individual patient.

17 NYHHS Policy No: 111-05.
 

VA Office of Inspector General 7 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

format. As a result, unit staff were unable to provide us a telemetry observation record 

for HD 3, and records for most other days in January were also missing. 

Staff Were Not Properly Trained on Monitoring Equipment

The AHA recommends that staff assigned to telemetry units receive initial and periodic 

refresher training on critical elements of cardiac monitoring. In addition, VHA policy 

requires that all personnel involved in the use of reusable medical equipment, such as 

telemetry monitors, have documented training on the setup, use, reprocessing, and 

maintenance of the equipment.18 

During our interviews of the unit nursing staff, the unit nurse manager, and a biomedical 

engineer, we received inconsistent responses as to what type of alarm would be generated 

in the event that a telemetry lead became disconnected from a patient’s chest. According 

to some staff, a “red alarm” would be triggered since a disconnected lead was considered 

critical; whereas other staff told us that a disconnected lead would trigger a yellow alarm 

or that it would not trigger any alarm at all. The staff were also inconsistent in their 

responses as to whether an ECG strip would automatically print if a lead became 

disconnected. However, all of the staff told us that an ECG strip would automatically 

print in the event of a red alarm. 

We visited the unit to have the biomedical engineer and the nursing staff demonstrate the 

use of the monitoring system. During our observation of the system demonstration, 

several patients experienced yellow or red alarm incidents in realtime, yet no ECG strips 

automatically printed. We found that the alarm parameters to automatically generate 

ECG printouts were not properly set up on the monitoring system for any of the alarms. 

Furthermore, neither the unit nursing staff nor the biomedical engineer in attendance 

knew how to set the parameters on the monitoring system. 

We also found that the unit nursing staff present did not know how to retrieve and print a 

patient’s electronically saved telemetry history. The monitoring system automatically 

stores each patient’s history for 24 hours and only purges it from the system once a 

telemetry box is cleared and connected to the next patient admitted. However, the history 

can be manually cleared once a patient is discharged. One physician we spoke to stated 

that an RN told him he would have to call the manufacturer’s customer service and speak 

to a technician in order to retrieve a telemetry history. 

Furthermore, we did not find evidence of competency training on the use of the telemetry 

monitoring system conducted by the manufacturer or any recent refresher training for the 

monitoring system in unit staff competency folders. For example, for one RN involved in 

the care of the subject patient, we found evidence of training that was last documented 

18 VHA Directive 2009-004, Use and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health 

Administration Facilities, February 9, 2009. 

VA Office of Inspector General 8 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

13 years ago; although, the RN’s competency records indicated that this training should 

have been occurring annually. 

Conclusion

We could neither confirm nor refute the allegation that a patient on the telemetry unit was 

not continuously monitored during his hospitalization in January, 2011, due to a 

disconnected telemetry lead, malfunctioning monitoring equipment, or short staffing. 

However, we did find that patient care documentation lacked sufficient detail to verify 

whether patients were, in fact, being continuously monitored while on the unit. In 

addition, we found that telemetry staff were not sufficiently trained in the use and 

understanding of the telemetry monitoring equipment to ensure that the correct patient 

parameters were set and that alarms sounded when necessary to alert staff to potential 

problems. Specifically, there was inconsistent knowledge among telemetry unit nursing 

staff as to the triggering events for various alarms, or even when an alarm would be 

triggered. As a result of these system weaknesses, patients on the telemetry unit are at 

increased risk of not being properly monitored. 

Recommendations

Recommendation 1. We recommended that the facility Director implement procedures 

to ensure that telemetry unit nursing staff comply with The Joint Commission and facility 

policies on charting and telemetry documentation to maintain a timely, complete, and 

accurate medical record for each patient. 

Recommendation 2. We recommended that the facility Director ensure that telemetry 

unit nursing and biomedical engineering staff receive initial and refresher training on the 

telemetry monitoring system in accordance with VHA and facility policies. 

Comments

The Veterans Integrated Service Network and Medical Center Directors concurred with 

the findings and recommendations and provided an acceptable action plan. We will 

follow up on the planned actions until they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 9 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date:	 October 2, 2011 

From:	 Director, VA New York/New Jersey Veterans Healthcare 

Network (10N3) 

Subj:	 Healthcare Inspection—Alleged Telemetry Unit Deficiencies, VA 

New York Harbor Healthcare System, New York, NY 

To:	 Director, Bedford Office of Healthcare Inspections (54BN) 

Thru:	 Director, Management Review Service (10A4A4) 

Attached please find the response to the draft alleged 

telemetry unit deficiencies report for VA New York Harbor 

Healthcare System (VANYHHS). 

The VISN concurs with the action plan submitted by the 

facility. 

Michael A. Sabo, FACHE 

VA Office of Inspector General 10 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

System Director Comments
 

Department of

Veterans Affairs Memorandum

Date:	 October 2, 2011 

From:	 Director, VA New York Harbor Healthcare System (630/00) 

Subject:	 Healthcare Inspection—Alleged Telemetry Unit Deficiencies, VA 

New York Harbor Healthcare System, New York, NY 

To:	 Director, VA New York/New Jersey Veterans Healthcare 

Network (10N3) 

This is to acknowledge receipt and review of the draft alleged 

telemetry unit deficiencies report for VA New York Harbor 

Healthcare System (VANYHHS). Thank you for the 

opportunity to comment on the recommendations for 

improvement contained in this report. If you have any 

questions, please contact Kim Arslanian, the Performance 

Improvement Manager at (718-630-2865). 

MARTINA A. PARAUDA
 

VA Office of Inspector General 11 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the facility Director 

implement procedures to ensure that telemetry unit nursing staff comply 

with JC and facility policies on charting and telemetry documentation to 

maintain a timely, complete, and accurate medical record for each patient. 

Concur Target Completion Date: 6/15/11 

Facility’s Response: 

Effective 6/15/11, the Associate Director, Patient Services (Chief Nurse) 

issued an e-mail to the appropriate Nursing management staff mandating 

compliance with the documentation requirements as per the current policy. 

In addition, a workgroup that includes the Associate Director, Patient 

Services, Associate Director Facilities and Human Resources and the 

Performance Improvement Manager has been meeting since July to review 

current telemetry practices and have modified the policy as per the 

suggestions made during the OIG site visit. The revised documentation 

will be scanned into CPRS. The final draft policy has been forwarded to 

the Clinical Executive Board (CEB) for review and approval. Once 

approved by the CEB the policy will be reviewed by the Executive Council 

(EC) for approval. Once approved, the revised policy will include a system 

for monitoring compliance and a medical record review to monitor 

documentation. The EC is scheduled to meet on Oct 26th . 

Status: Policy approval pending CEB and EC approval. 

Recommendation 2. We recommended that the facility Director ensure 

that telemetry unit nursing and biomedical engineering staff receive initial 

and refresher training on the telemetry monitoring system in accordance 

with VHA and facility policies. 

Concur Target Completion Date: 9/6/11 

VA Office of Inspector General 12 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Facility’s Response: 

The manufacturer provided training for all appropriate staff on several days 

(July 12, 13, 14, 28, August 1, 2, and September 6). 98% of staff were 

trained. Remaining 2% reflect those staff on extended leave. 

In addition, Nursing Education has developed a curriculum for training new 

and current employees. The plan will be added to TMS for tracking and 

assigned to all appropriate employees. Initial and annual competency 

assessment checklists were reviewed as well. 

Status: Complete 

VA Office of Inspector General 13 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

OIG Contact and Staff Acknowledgments
 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Claire McDonald, MPA, Project Leader 

Glen Pickens, RN, MHSM, Team Leader 

Thomas Jamieson, MD 

Frank Keslof, EMT, MHA 

VA Office of Inspector General 14 
Alleged Telemetry Unit Deficiencies, VA New York Harbor Healthcare System, New York, NY 

Appendix B

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New York/New Jersey Healthcare Network (10N3) 

Director, VA New York Harbor Healthcare System (630/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Charles E. Schumer, Kirsten E. Gillibrand 

U.S. House of Representatives: Carolyn B. Maloney 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 15