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.