A patient at the Rocky Mountain Regional VA Medical Center in Aurora died last year after a hospital staff member turned off their notification device alerting them to the veteran’s rapidly declining condition.
An investigation by the VA’s Office of Inspector General found, in spring 2023, a telemetry medical instrument technician missed several red alarms concerning the patient’s oxygenation levels. By the time clinicians arrived, the individual was “unresponsive and pulseless,” inspectors found.
Telemetry remotely measures and collects clinical data, including respiratory rate, pulse rate, oxygen saturation and blood pressure. Technicians receive alerts depending on patients’ conditions and are supposed to alert nurses in the event of rapid changes.
Hospital staff told investigators that this technician regularly changed patient alarm settings and placed communication devices on “do not disturb” for long periods of time.
Leadership in September 2022 became aware of technicians not adhering to alarm monitoring expectations, the report notes. Brass at that time provided education in staff meetings and issued a letter of expectations. A nurse manager told investigators they had completed audits of alarm monitoring a few times a month but could not provide any records to investigators.
Hospital staff did not file a patient safety report for the patient death — an omission one manager called “extremely…
