Falsification of Blood Pressure Readings at the Berea Community Based Outpatient Clinic, Lexington, Kentucky

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns that a primary care provider (PCP) at the Berea, Kentucky, Community Based Outpatient Clinic (CBOC) of the Lexington VA Medical Center falsely documented patients’ blood pressure (BP) readings. In 1,364 of 1,370 (99.5 percent) primary care encounters where patients had diagnoses that placed them at greater risk for adverse clinical outcomes, the PCP documented repeat BP readings of 128/78. An OIG physician reviewed 64 of these patients because they met pre-selected high-risk criteria, and uncontrolled hypertension (HTN) would increase the likelihood of adverse clinical outcomes, including death. For the 64 patients, the PCP rarely added or changed medications for HTN, and scheduled nine-month follow-up appointments for most patients irrespective of the complexity of their conditions and sufficiency of BP control. The PCP’s inaction and inadequate surveillance related to HTN exposed patients to continued risk for adverse clinical outcomes. The PCP related documenting the 128/78 BP readings to “turn off” clinical reminders; however, the OIG concluded that the PCP’s falsification of BP readings was most likely an effort to reduce workload. The facility did not have processes in place to validate performance measure data, and a licensed practical nurses (LPN) at the CBOC did not appropriately document BP recheck values when the initial BP was elevated. Further, the OIG concluded that it was more likely than not that the PCP and LPN knew, or should have known, about each other’s deficient practices but did not take action. Facility leaders took prompt and appropriate steps to evaluate the PCP’s actions and mitigate risk to patients. The OIG made seven recommendations to the Facility Director related to administrative actions, patient care follow-up, data integrity, policy and procedure development, and staff training.