Falsification of Blood Pressure Documentation in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident by not ensuring that a Licensed Vocational Nurse (LVN) documented actual blood pressure readings prior to administering antihypertensive medication. The resident in question had a history of heart failure, cardiomegaly, and essential hypertension, and required substantial assistance with daily activities due to severe cognitive impairment. According to the resident's medication orders, blood pressure was to be checked and documented before administering diltiazem, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. On multiple occasions, the LVN documented blood pressure readings in the Medication Administration Record (MAR) at 1 p.m. that were identical to those recorded at 9 a.m. on the same days, rather than recording the actual readings taken at the later time. During interviews, the LVN admitted to copying the earlier readings instead of documenting the true values, citing a fast-paced work environment and a high resident load as reasons for this action. The Director of Nursing confirmed that this constituted falsification of documentation, as staff are required to document blood pressure readings in real time and accurately reflect the resident's condition. Facility policies reviewed also emphasized the importance of timely, accurate, and comprehensive documentation in the medical record.