Failure to Prevent Blood Pressure Measurements on AV Fistula Arms in Dialysis Residents
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for two residents with end stage renal disease who required hemodialysis and had arteriovenous fistulas (AVF) in their left arms. For one resident, despite a care plan and physician order specifying to avoid taking blood pressure (BP) on the left arm with the AVF, BP measurements were recorded on that arm on three separate occasions. The Director of Nursing confirmed these incidents and acknowledged that BP should not be taken on the arm with the fistula, as per the resident's orders and care plan. For the second resident, the care plan indicated no BP should be taken on the arm with the AVF, and a visible sign was posted in the resident's room to this effect. However, BP was taken on the left arm on multiple occasions, and there was no physician order in place to avoid using the left arm for BP assessments. Both the licensed nurse and the assistant director of nursing confirmed that BP should not be taken on the AVF arm and that a physician order should have been present. The facility's policy and national guidelines also support avoiding BP measurements on the AVF arm.