Failure to Document Pre-Dialysis Blood Pressure for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with multiple complex medical conditions, including end-stage renal disease, heart failure, and hypotension during hemodialysis. According to physician orders, the resident was to have vital signs, including blood pressure, checked every shift and prior to being transported to dialysis. On the date in question, there was no documentation of the resident's blood pressure being taken before she was sent to dialysis, as required by both physician orders and the resident's care plan. Record reviews showed that the last documented blood pressure was from the previous evening, and there was no entry for the day of dialysis on the electronic record, medication administration record, treatment administration record, or the dialysis communication form. Interviews with nursing staff revealed that the nurse responsible for preparing the resident for dialysis stated he had checked her vitals and that they were within normal range, but he could not recall the specific reading and admitted he must not have documented it. The Director of Clinical Services and the ADON confirmed that there was no documentation of the blood pressure reading for that day and acknowledged the importance of this documentation for resident care. The deficiency was identified through interviews and record reviews, which confirmed that the required documentation was missing. The facility's own in-service training materials emphasized the importance of following physician orders and accurate documentation to ensure continuity of care and compliance with regulations. Despite this, the failure to document the resident's blood pressure prior to dialysis was not in accordance with accepted professional standards and practices.