Inaccurate Documentation of Blood Pressure Site for Dialysis Patient
Penalty
Summary
The facility failed to ensure that a resident's medical records contained accurate documentation regarding vital signs. Specifically, a resident with multiple diagnoses, including high blood pressure and end stage renal disease requiring dialysis, had a physician's order stating that blood pressure should not be taken on the left arm, which had a fistula. Despite this order, documentation showed that blood pressure was recorded as being taken on the left arm on multiple occasions. During an interview, a registered nurse acknowledged that while nurses are aware not to take blood pressure from a fistula arm, they may have inaccurately documented the site, recording the left arm when they actually used the right arm. This resulted in inaccurate documentation in the resident's medical record.