Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Telemetry Unit Issues 

John Cochran Division, 

St. LouisVA Medical Center 

St. Louis, Missouri 

Report No. 10-00231-113 March 7, 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) 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Executive Summary 

At the request of the Honorable Russ Carnahan, United States Representative from

Missouri, the VA Office of Inspector General (OIG) Office of Healthcare Inspections

reviewed the validity of allegations related to the availability of personal protective

equipment (PPE) and blood pressure machines, staff compliance with isolation

precautions, and functionality of equipment on the telemetry unit at the John Cochran

Division of the St. Louis VA Medical Center, St. Louis, MO.

We substantiated that PPE was not always available on the telemetry unit; however, this

issue was resolved prior to our site visit. We substantiated that blood pressure machines

may not have always been available on the telemetry unit; however, we determined that

staff could secure additional machines through Logistics Service as needed for patient

care. We did not substantiate that staff did not follow proper isolation precautions when

caring for infectious patients. We substantiated that some equipment needed for patient

care on the telemetry unit was non-functional at the time of the complaint; however,

actions had been taken by management or were ongoing to address the issues prior to our

visit. We also noted that managers established an executive office action line for staff to

report their concerns to leadership. As the issues reviewed had largely been addressed

and resolved at the time of our visit, we made no recommendations.

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO:	 Director, VA Heartland Network (10N15)

SUBJECT:	 Healthcare Inspection – Telemetry Unit Issues, John Cochran Division,

St. Louis VA Medical Center, St. Louis, Missouri.

Purpose

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

allegations forwarded to us by the Honorable Russ Carnahan, United States

Representative from Missouri, related to the availability of personal protective equipment

(PPE) and blood pressure machines, staff compliance with isolation precautions, and the

functionality of equipment on the telemetry unit at the John Cochran Division (JCD) of

the St. Louis VA Medical Center (STLVAMC), St. Louis, MO.

Background

The STLVAMC is a two-division, tertiary care facility in Veterans Integrated Service

Network 15. JCD is located in downtown St. Louis, MO. It has 136 acute care beds and

provides acute medical and surgical services and a wide range of specialty care. The JCD

also operates a 28-bed telemetry unit that, due to scheduled renovations, temporarily

relocated from ward 7N to ward 7S on August 23, 2010.

PPE is specialized clothing such as gowns, gloves, masks, shoe covers, and hair covers

that are worn by caregivers to protect against the transmission of infectious agents.

Isolation precautions are special precautionary practices and procedures used in the care

of patients with contagious or communicable diseases. The type of infectious disease

dictates the isolation precautions used to prevent the spread of the disease.

In August 2010, clinical staff members sent a letter to Congressman Carnahan alleging

multiple issues on the telemetry unit at the JCD, as follows:

 PPE, specifically gowns, were not always available.

 Automated blood pressure machines were not always available.

VA Office of Inspector General 1 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

	 Staff did not always comply with isolation precaution requirements.

	 Automated blood pressure machines did not give blood pressure readings during

two Code K (respiratory and cardiac arrest events) incidents in August 2010.

	 Fundascopes (used for eye examinations) and otoscopes (used for ear

examinations) had been inoperable for over 3 years.

	 The fax machines and call light system had been nonoperational for an extended

period of time.

The clinical staff members indicated that these issues had been ongoing for weeks to

years and that written communications and personal meetings with facility managers over

the previous 8–10 months had not resolved the problems.

The clinical staff members also cited personnel-related issues, which were outside of the

OIG’s purview and are not addressed in this report.

Scope and Methodology

We visited the JCD November 16–18, 2010. We interviewed the clinical staff members,

Associate Director for Patient Care Services, Medical Center Associate Director, and

Logistics Service1 staff. We also interviewed telemetry unit staff including the acting

nurse manager, registered nurses, licensed practical nurses, and nursing assistants. We

reviewed patient advocate information, email messages and other documents provided by

the clinical staff members and interviewees, infection control monitoring data and

meeting minutes, Critical Care Committee meeting minutes and post-Code K evaluations,

and equipment preventive maintenance records and work order logs.

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

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

Efficiency.

Inspection Results

Issue 1: Availability of PPE and Blood Pressure Machines

We substantiated that PPE was not always available on the telemetry unit; however,

management resolved this issue prior to our site visit. Staff told us that prior to

September 2010 they did not have sufficient numbers of cloth gowns, which required

laundering, available to care for isolation precaution patients. The JCD converted to

disposable gowns in September 2010, and staff confirmed that gowns are now routinely

available.

1 Logistics Service is responsible for providing equipment for patient use throughout the facility.

VA Office of Inspector General 2 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

We substantiated that blood pressure machines may not have always been available on

the telemetry unit; however, we determined that staff could secure additional machines

through Logistics Service as needed for patient care. One of the clinical staff members

explained that the telemetry unit had four standard blood pressure machines, and if one

was used on an isolation patient, the practice was to leave the machine in the patient’s

room until the patient was discharged, transferred, or no longer required isolation

precautions. The machine would then be sent to Logistics Service for cleaning. The

clinical staff member reported that this practice resulted in a shortage of blood pressure

machines available for use on other telemetry patients.

Managers told us that staff had been instructed to contact Logistics Service when

equipment such as blood pressure machines were needed, and nursing staff we

interviewed were aware of the process to secure replacement equipment. None of the

telemetry staff interviewed could recall any instances when they were unable to obtain

additional blood pressure machines.

The STLVAMC purchase of disposable gowns and staff’s ability to obtain equipment

when needed from Logistics Service appear to have resolved the issues.

Issue 2: Compliance with Isolation Precautions

We did not substantiate that staff did not routinely follow proper isolation precautions

when caring for infectious patients. During our interviews with the unit staff, we learned

of one instance when a nurse did not follow procedure and entered an isolation room

without any PPE. Managers addressed the nurse’s conduct appropriately.

Infection control monitors and committee minutes from January 1, 2009, through

July 31, 2010, did not reflect any infection spikes or outbreaks on the telemetry unit

which might be indicative of staff non-compliance with isolation precautions.

Issue 3: Functionality of Equipment

We substantiated that some equipment needed for patient care on the telemetry unit was

non-functional at the time of the complaint.

Fundascopes and Otoscopes: Managers confirmed that fundascopes and otoscopes in

some telemetry unit rooms were occasionally rendered non-functional because parts

(such as earpieces and connectors) were removed and used in other areas. Managers

reported that missing parts have been repeatedly replaced; however, the problem

continues to recur. Managers have instructed staff to conduct a daily inventory upon

arrival and contact Logistics Service to obtain replacement parts, as needed. Staff

confirmed that they are able to secure the necessary items and parts through Logistics

Service.

VA Office of Inspector General 3 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Fax Machine: We reviewed work order reports and confirmed that the old 7N fax

machine was problematic. At the time of our visit, the fax machine had been replaced,

and staff reported that the replacement fax machine functioned properly.

Call Lights: Managers confirmed that the nurse call light system on 7N had significant

repair issues due to age and inability to obtain replacement components. There were

54 work orders submitted for call light system repairs between January 1, 2010, and

August 23, 2010. The average turnaround time for repairs during that time period was

19 days. Since the relocation to 7S, there have not been any problems with, or work

orders related to, the call light system.

Code K Events: We found no evidence to support the allegation that automated blood

pressure machines malfunctioned during two Code K events in August 2010. Local

policy requires analysis of Code K events to include equipment issues. The clinical staff

members could not provide the dates or patient names for the Code K events. Therefore,

we reviewed post-Code K report forms and Critical Care Committee meeting minutes

from June 1–October 31, 2010, to determine whether any equipment malfunctioned

during codes. We found no documented evidence of equipment malfunctions during any

of the Code K events. We further determined that all automated blood pressure machines

received appropriate annual preventive maintenance checks in 2010.

We noted that in Code K situations, some patients may experience irregular blood flow

which would not be detected by an automated blood pressure machine. As such, this

condition could give the appearance that the blood pressure machine was not functional.

Staff confirmed that they use a manual blood pressure device if the automated blood

pressure machine does not provide a reading.

In February 2010, managers implemented a mechanism for staff to anonymously report

concerns to leadership through an executive office action line. We reviewed a sample of

telemetry unit-related complaints and found that, in general, management responded to

the identified concerns and had documented follow up in email strings.

Conclusions

We substantiated that PPE was not always available on the telemetry unit; however,

management resolved this issue prior to our site visit. We could not substantiate that staff

did not routinely follow proper isolation precautions when caring for patients or that

equipment was unavailable. We substantiated that some equipment needed for patient

care on the telemetry unit was non-functional at the time of the complaint; however,

actions had been taken or were ongoing to address the issues prior to our visit. Managers

established the executive office action line to allow staff to anonymously report their

concerns to leadership. As the issues reviewed had largely been addressed and resolved

at the time of our visit, we made no recommendations.

VA Office of Inspector General 4 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Comments

The VISN and Medical Center Directors agreed with our findings (see Appendixes

A and B, pages 6–7, for the Directors' comments). We made no recommendations and

plan no further actions.

 (original signed by:)

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

Assistant Inspector General for

Healthcare Inspections

VA Office of Inspector General 5 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: February 15, 2011

From: Director, VA Heartland Network (10N15)

Subject: Healthcare Inspection – Telemetry Unit Issues, John Cochran 

Division, St. Louis VA Medical Center, St. Louis, Missouri 

To: Director, Atlanta Office of Healthcare Inspections (54AT)

Thru: Director, Management Review Service (10B5)

1. Thank you for the opportunity to review this report. I concur

with the report and have no comments.

2. Should you need additional information, please contact our

office at (816)-701-3000.

(original signed by: )

JAMES R. FLOYD, FACHE 

Director, VA Heartland Network VISN 15 

VA Office of Inspector General 6 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Appendix B

Medical Center Director Comments

Department of

Veterans Affairs Memorandum

Date:	 February 16, 2011

From:	 Director, St. Louis VA Medical Center, John Cochran

Division (657/00)

Subject:	 Healthcare Inspection – Telemetry Unit Issues, John Cochran 

Division, St. Louis VA Medical Center, St. Louis, Missouri 

To:	 Director, VA Heartland Network (10N15)

1.	 Thank you for the opportunity to review this report. I concur

with the report and have no comments.

2.	 Should you need additional information, please contact our

office at (314)-289-7651.

(original signed by:) 

RIMAANN O. NELSON, RN, MPH/HSA 

Director, St. Louis VA Medical Center 

VA Office of Inspector General 7 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact Toni Woodard, Project Leader

Atlanta Office of Healthcare Inspections

Acknowledgments Susan Zarter 

VA Office of Inspector General 8 
Telemetry Unit Issues, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri 

Appendix D

Report Distribution 

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VA Heartland Network (10N15)

Director, St. Louis VA Medical Center, John Cochran Division (657/00)

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: Roy Blunt, Claire McCaskill

U.S. House of Representatives: Todd W. Akin, Russ Carnahan, William Lacy Clay, Jr.

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

VA Office of Inspector General 9