Failure to Accurately Document Vital Signs and Blood Pressure in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, specifically regarding the documentation of vital signs and blood pressure readings. For one resident with multiple chronic conditions, including end stage renal disease and hypertension, the vital signs were not accurately documented in the Medication Administration Record (MAR) on a specific date, with identical readings entered for both morning and evening despite the resident being hospitalized part of that day. For another resident with chronic kidney disease and dependence on dialysis, blood pressure readings were inconsistently documented in both the blood pressure log and the MAR throughout the month, with several instances where readings were missing or not recorded at the required times for medication administration. A third resident, also with significant cardiac and renal diagnoses, had blood pressure readings that were either duplicated or not accurately entered in the records. Interviews with nursing staff revealed that sometimes previous blood pressure values would automatically populate in the electronic record, and staff would not always update them with current readings. Some staff admitted to not always recording the blood pressure after taking it, and there was no consistent process for auditing the accuracy of these entries. Staff also indicated uncertainty about the timing and content of in-service training related to medication administration and documentation. The facility's own documentation policy requires that all services, including medication administration and vital sign monitoring, be objectively, completely, and accurately recorded in the resident's medical record. The lack of accurate documentation could affect the care and treatment of residents, as the records did not reliably reflect the assessments and interventions performed. The deficiency was identified through record review and staff interviews, which confirmed that the required documentation was not consistently or accurately maintained for the residents involved.