Blood Pressure Documentation Error in a Patient With Left Arm AV Fistula

Case Summary

The patient receives hemodialysis and has a left arm arteriovenous (AV) fistula. The clinician documented that the patient’s blood pressure was obtained from the left arm, which is inconsistent with standard dialysis precautions. This discrepancy was identified during QA review, corrected in the medical record, and communicated to the clinician for education.

Clinical Impact

Taking blood pressure on the arm with an AV fistula may compromise the vascular access, increase the risk of clotting or damage to the fistula, and potentially interfere with the effectiveness of dialysis treatment.

CMS Regulatory Impact

CMS requires clinicians to follow accepted standards of practice and incorporate patient-specific precautions into the comprehensive assessment and plan of care. Failure to observe dialysis access precautions may raise concerns regarding patient safety and quality of care.

Risk Management/Quality Impact

Documentation indicating blood pressure was taken on the fistula arm may create liability concerns and suggest noncompliance with established dialysis safety protocols. The issue was identified and corrected during QA review, and the clinician was notified to prevent recurrence.

Business Impact

• CMS Star rating
• Providing improper services