Inaccurate Documentation of Blood Pressure Site for Resident with AV Shunt
Penalty
Summary
The facility failed to accurately document the site of blood pressure measurement for one resident with end stage renal disease who required hemodialysis via an arteriovenous (AV) shunt in the left arm. Review of the resident's medical records showed that a licensed vocational nurse (LVN) documented blood pressure checks as being performed on the left arm on multiple occasions, despite the resident's order summary indicating that no blood pressure checks or blood draws should be performed on the left arm due to the presence of the AV shunt. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for varying levels of assistance with daily activities. During interviews, the LVN acknowledged making documentation errors regarding the site of blood pressure measurement and stated that she should have reviewed her documentation for accuracy. The resident confirmed that blood pressure was only taken on the right arm, never on the left. The Director of Nursing emphasized the importance of accurate and complete documentation to ensure proper monitoring and avoid assumptions. The facility's policy required that medical record entries be complete, legible, descriptive, and accurate, and outlined the procedure for correcting errors.