Physician’s Falsification of VA Video Connect Blood Pressures at the North Las Vegas VA Medical Center in Nevada

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding a primary care provider (provider) potentially falsifying blood pressure readings (blood pressures) at the North Las Vegas VA Medical Center (facility) in Nevada. The OIG determined the provider knowingly documented false blood pressures in patients’ electronic health records (EHRs) during VA Video Connect (VVC) visits. The provider attributed the falsifications to the belief that the VVC template required documentation of a blood pressure when a blood pressure was not obtained and to a lack of VVC training. The OIG confirmed that the VVC template did not require documentation of blood pressures and determined the provider completed required VVC trainings. The provider reported patients were not harmed by the falsifications because mitigation strategies were used. From a review of a sample of EHRs, the OIG determined the provider did not use the mitigation strategies with most patients; however, the OIG did not find evidence that any patients experienced an adverse clinical outcome as a result of the false blood pressures. Upon learning of the provider’s falsification of blood pressures, facility leaders took actions that included retraining and facilitating an EHR review. Despite the retraining, the provider continued to display difficulty demonstrating the use of technology and locating the VVC template. The OIG evaluated a sample of EHRs from the facility’s review and found that not all entries with a blood pressure of 120/80 were clinically reviewed and amended. Additionally, the OIG determined that facility leaders failed to initiate state licensing board reporting processes. The OIG made five recommendations to the Facility Director related to verifying the provider’s ability to complete and document VVC visits, considering administrative action, initiating state licensing board reporting processes, and ensuring the provider’s blood pressure entries in EHRs are reviewed and amended.