Inaccurate Documentation of Blood Pressure Site for Dialysis Resident
Penalty
Summary
The facility failed to ensure accurate documentation of blood pressure (BP) measurement sites for a resident with end stage renal disease requiring dialysis. The resident had a physician order specifying that BP should not be taken on the right arm due to the presence of a fistula/shunt. However, a review of the medical record showed that BP was documented as being taken on the right arm 13 times over a one-month period. Interviews with nursing staff revealed that vital signs were obtained by Certified Nursing Assistants and entered into the medical record by nursing staff, who sometimes selected an arm at random or documented the site incorrectly due to rushing. Staff confirmed that some of the BP entries indicating the right arm were inaccurate and that the actual site used was the left arm. The D-Wing Unit Manager acknowledged that the medical record was inaccurate when BP was documented as being taken on the right arm but was actually taken on the left. She also stated that she did not audit vital sign records. The facility's policy required all medical records to be complete, accurately documented, readily accessible, and systematically organized, but this was not followed in the case of this resident.