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Patient Died at New York VA Hospital After Alarm Was Ignored

The Veterans Affairs Office of Inspector General again found problems with the care provided by nurses in a cardiac monitoring unit at the VA hospital in Manhattan.

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Registered nurses at a Manhattan Veterans Affairs hospital failed to notice a patient had become disconnected from a cardiac monitor until after his heart had stopped and he could not be revived, according to a report Monday from the VA inspector general.

The incident from last June was the second such death at the hospital involving a patient connected to a monitor in a six-month period. The first, along with two earlier deaths at a Denver VA hospital, raised questions about nursing competency in the VA system, ProPublica reported last month.

The deaths also prompted a broader review of skills and training of VA nurses. Only half of 29 VA facilities surveyed by the inspector general in a recent report had adequately documented that their nurses had skills to perform their duties. Even though some nurses "did not demonstrate competency in one or more required skills," the government report stated, there was no evidence of retraining.

Monday’s report documents the June 2011 death of patient in his 80s at the Manhattan campus of the VA’s New York Harbor Healthcare System. The man had undergone several heart procedures and needed to have his vital signs continuously monitored, the report said.

On his fifth day at the hospital, monitor records show that an alarm indicated a problem with the device or the patient. But there is no evidence nurses were aware of the alarm until the man was discovered unresponsive an hour and a half later. He was declared dead shortly afterward, the report said.

“The patient’s telemetry status was not effectively monitored at the time of his death due to a lack of awareness of the disconnected lead,” inspectors concluded.

Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes.

Ironically, federal inspectors were in the hospital the same month to investigate the first death, which occurred in a different monitoring unit in January 2011.

During that investigation, the inspectors discovered nurses at the hospital didn't understand how the monitors even worked. None of those interviewed could accurately explain what would happen if a patient became disconnected from a cardiac monitor.

Inspectors also found no evidence that the nurses' competence had been checked. Records showed that one of the patient's nurses had last received training on the monitors 13 years earlier, according the October 2011. The report recommended sweeping changes and retraining, which the hospital agreed to implement.

IG inspectors were not notified of the second death at the Manhattan facility until someone complained in November 2011, five months after the alarm was missed and the patient died.

The latest report does not recommend any additional changes or training at the hospital because “managers have made significant progress” after the first report.

In a response to the inspector general, the hospital acknowledged receipt of the report and said it concurred with the document. A spokeswoman for the VA in Washington didn’t immediately respond to our requests for comment.

Violet Pucsek

May 15, 2012, 1:55 p.m.

Monitoring the status of heart patients is basic nursing.  If they don’t understand this they are not qualified to be hired as nurses.  Veterans deserve better than this terrible shoddy treatment.

fiasco fortuna

May 15, 2012, 2:33 p.m.

This just proves the old military saying, you are given two opportunities to give your life to you country: once on the battlefield, and again in the VA hospital.

You seldom hear of this sort of thing in a private hospital or one associated with a religious organization.  That’s because the first person notified in those organizations when someone dies or is injured under questionable circumstances is their legal staff.  The first person survivors, or the injured party, will see is not one of the doctors, but a lawyer, most often than not offering shut up and go away money.  As a user of both the military medical system and the VA with a couple of chronic problems, I have always found the care to be good.

Alberta Harbutt

May 15, 2012, 2:44 p.m.

I once had a nurse supervisor living in my apt house.  She
was dealing with a local hospital where all the nurses were
from a given country—and she was dumbfounded at how
little they cared about their patients.  She was truly shocked!

Corey Mondello

May 15, 2012, 2:48 p.m.

Well obviously to save even more money, Conservatives need to make more cuts in the evil socialist VA. This would cut down on pay for staff, and more “accidents” can happen.

I used to work at the Manhattan VA back in 1970’s.
The nurses always gave good care back then.
I am surprised at the lack of education the nurses
have now a days.
I always had the up most respect for the veterans
we cared for.  I
We need to thank them better for their service by
giving them excellent care.
I hold administration responsible.

Kathy Einwich

May 15, 2012, 3:52 p.m.

Don’t blame the nurses!  Blame cutbacks for not enough staff!  I agree with Corey Mondello.  The nurses do the best they can in situations like these.  Hold the administration, all the way up to CONGRESS, responsible.  It’s unfortunate that you can’t really sue the Government.

Jawaralal Schwartz

May 15, 2012, 5:24 p.m.

Yes, thank the nurses for their service.  Their managers should be disciplined, or better, fired, for not noticing the nurses did not know how to use the monitors.  Further, the doctors responsible for this travesty should be terminated.  Not retrained, just fired.  There are many eager to take these jobs.  Time to clean out all the incompetents and negligent managers and executives.  Criminal prosecution might also be considered.

Quit blaming Republicans for everything. This is about poor care by an incompetent staff, not budget cuts.

Michael Mackenzie

May 15, 2012, 6:35 p.m.

No surprises here. Care provided by the VA Health Admin is inferior across the board. Not only are they underfunded, they are staffed for the most part by the second string. Vets deserve better.

checking a monitor should be not less than hourly.  to not know that one is not operational is negligent.
a good monitor would have an alarm to signal if any leads became nonfunctional and thats what happened
the nurses were not fit for duty in the environment provided
fix it

The VA system in this country MUST be held accountable for the lack of care to our precious veterans.  Last October, my son, a Marine who served three tours in Iraq met with a therapist for help with PTSD.  His medical records show that he was in desperate condition, telling of his recent flashbacks, insomnia, road rage, general irritability to the point that while driving he would often have a flashback and had to pull off of the road because he couldn’t figure out if he was still in Iraq or here.  The therapist let him walk out the doors of the VA Hosp. in Dayton, Ohio.  A month later, he committed suicide.  I, his mother, was listed as his emergency contact but whomever he saw, didn’t see fit to make a call that would have probably saved his life.  After his death, I requested his medical records and was absolutely sick to my stomach when I found out what he had endured in his three years in the war.  Something HAS to be done to get families involved in treatment for PTSD and TBI.  My son was a young 29 year old who had the rest of his life to live but because of a negligent “therapist” who had seen him for almost three months prior to his death, didn’t pick up the telephone to let anyone in the family know his condition.  Our beloved veterans and their families deserve BETTER than what they are getting.  If it takes my last breath on this Earth, I am going to see that things are changed and families will be the first contact when a veteran is seen for PTSD and/or TBI.  Often they abuse alcohol or drugs, compounded with PTSD and TBI.  This is a lethal combination, that, without the proper treatment will end in disaster as did my son’s life.  I don’t know how to carry on without my son . . . .the irony is he survived three and a half long years in the warzone . . . . but couldn’t survive in civilian life back here in the states.  Something is terribly, terribly wrong with the “system”.

Mary Hoettels

May 15, 2012, 11:28 p.m.

Jody, my heart aches for you in the loss of your son.  He with many others are getting substandard care despite volunteering and committing themselves to defend the constitution and uphold democracy.

My daughter served in Afghanistan and fought in combat with the Taliban before Congress even knew women were out there doing what they were trained to do.  She was turned away by the VA hospital she went to because women are not real soldiers.

I had the same experience and still fight for my care and getting someone to help me with my PTSD.  I have had to push to get the correct cancer care for my spouse who served two tours in V. Nam and still deals with PTSD.

Incompetent administrators, physicians, nurses, staff and employees are never fired; they are just relocated to another hospital clinic or to work in another VA hospital. 

It will take a lot of work to get the VA to become responsible.  It is also important to look at care for our wounded veterans all through their life cycle and get resources in place. We need a support system where a family can get support and information as they help their veteran get their rightly deserved benefits and complete health care.

There are many who feel the same way you do.  The various veteran groups are continuously lobbying Congress for more financial allocation for providing care.  Unfortunately, those who have not served and have health care plans which provide access to outstanding care, do not understand the promise made to our military members must be kept.  The budget must never, never be balanced on the back of those who have served this country.

My prayers are with you.

ALL hospitals must be held accountable!!! Over 100,000 die every year due to hospital or medical errors! We went to war over the deaths at the World Trade Center! We must go to war over these deaths and demand an end to these kind of mistakes!

Nursing staff at the VA hospital in Memphis killed my brother.  While I was visiting him one day, the nurses were moving him from one bed to another when his IV feel to the floor.  Time went by before I could get a nurses’ attention to tell her about the IV.  She came to the room and picked up the IV from the floor and was going to re-insert it.  I made her stop and get a new IV.  She got mad and I threatened to report her.  She said “God can’t fire me!  I have a job for life and don’t care what you do!”  Sadly, my brother died a few weeks later.  Oh, he walked into the hospital for blood work and came out a paraplegic, having contracted a rare Staph infection while in the hospital.  VA hospitals need to be closed down and patients referred to private hospitals before more veterans die.

The VA system is like a patchwork quilt. Some are wonderful - the Lexington, KY VA is one of those - and some are houses of horror. And some are great in one area, and lousy in another. There needs to be a way to target the bad ones and reward the good ones.

After ruling out machine error, Terminate by firing the charge nurse and the patient nurse; this gross error cannot be tolerated. Also suggest every cardiac ICU nurse be forced to retrain to the point that he/she is expert on the techniques by obtaining their signatures on a document certifying their level of training. I was a clinical lab inspector back in the 1970’s and can verify that some, not all, VA hospitals were death traps. We shut down some of them. Our local VA hospital in Portland, Oregon is an excellent institution, one I would not hesitate using. I have personally witnessed extraordinary cardiac ICU nursing and physicians work at this shop and cannot compliment them more.

I remember when a family member was in an acute care facility, the staff would sit around the nurses station, eat and chat while alarms were going off. Most of the people in this facility were hooked up to breathing machines.  The alarms went off when the patients were struggling to breathe.  I spent every waking moment at my family member’s bedside to be her advocate.

Unfortunately this is going on everywhere.  And it’s beyond inhumane when people just show up to work when they are dealing with life and death situations.

What is the answer?  You could have a health care facility on every corner, but it still wouldn’t matter if the people that work there are incompetent.

As a nurse I cannot think of why this patient was not checked on before the hour and a half went by and he was found without a pulse….especially patient’s with monitors!!! Frequent checks are a must!

This is so unfortunate but not surprising.  I have worked in the Health Care Field for 30years and I can tell you that the caliber of people that work in the hospitals, Long term care centers etc are so far from being empathetic or compassionate.  It is not only in the VA but across all boards when it comes to care.  I have worked along side of people who did not have the right license or certification to take care of a dog let alone a human.  Sad but true.

February 2011, my father unexpectedly had “routine” neck surgery at Southern New Hampshire Medical Center.  Less than 24 hours after surgery my father was “found” unresponsive in his room; partially naked. His neck brace was on; front piece appeared to be torn off!  It was obvious there were signs of a struggle.  Once the nurses were notified medical records reflect that it took the nurses 5 min to respond, another 5 min went by and a code blue was called.  Took 18 min to get a pulse. He ended up being rushed to ICU, machines doing a 100% of the breathing for him.  When my brother & I saw our father, his neck was severely bruised and very swollen.  The hospital tried to cover it up by placing a hand towel over his neck. I was told it was to help with all the tubes???  Why should a patient ever be “found” in a hospital?  The more and more I research the more I see it.  A 69 yr. old man who is a diabetic, has had kidney problems, and issues with his heart , less than 24 hours after surgery; and not be connected to a heart monitor.  “It wasn’t deemed necessary” I was told.  No alarms went off and no one knows how long he was down. Completely Unacceptable could have been anywhere from 10 - 30 min.  Now there are saying it was due to a clot. Whether it was due to a clot or not is irrelevant, a man was unable to breathe in a hospital and no one came to assist.  I honestly feel that the clot ruptured as a result of the stress and anxiety he was under trying to get the neck brace off. There is evidence that he was struggling. Oddly enough, when I spoke to the chief medical examiner she quoted, there is no question in anybodys mind that your father in fact did struggled to breathe.  (let me finish the sentence…and no one responded to help himn either)  I can only imagine what my father was going through in that hospital room the last minutes of his life.  It is clear that his neck began to swell as a result of his surgery and the neck brace was basically suffocating him!  Why else would his neck be bruised so badly, and the front piece of the collar torn off?  My father was fighting for his life to breathe!  The latest excuse I have been given, “There are no guarantees that the nurses would have been able to respond to your father in time.”  I was appalled, so it is okay that a man in a HOSPITAL is down the hall fighting for his life, trying to remove a neck brace so he can breathe; and no one to help him!  My father lost his life.  Now imagine if this was your father?

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