NORTH LAS VEGAS, Nev. (KLAS) — A physician knowingly falsified blood pressure readings for numerous patients at the North Las Vegas VA Medical Center and the response from facility leaders was inadequate, according to the Office of the Inspector General at the Department of Veterans Affairs.
The falsified blood pressure readings occurred during virtual visits through a patient’s mobile device or home computer, the report said.
The report obtained by the 8 News Now Investigators does not disclose the provider’s name. A spokesman for the VA also refused to provide the individual’s name, but confirmed that the individual is a physician providing primary care and is still employed by the VA in southern Nevada.
Out of 330 blood pressure entries in patient electronic records, 270 — or 82% — were documented as 120/80, according to the OIG report.
“[T]he accuracy of which was highly unlikely as these measurements were expected to vary across multiple patients,” Assistant Inspector General for Healthcare Inspections Dr. John D. Daigh, Jr. wrote in the report.
The OIG investigated further and found that the provider entered blood pressures of 120/80 for 312 patients between January 1, 2020, and January 12, 2022, according to the report.
The physician claimed they thought that the template for the virtual visits required providers to document false blood pressures and that they did not receive training for the virtual visits, according to the report. However, the OIG observed that other providers were able to skip the section to enter blood pressures, rather than falsify the numbers. The OIG also stated that the provider’s claim about not receiving the proper training was false.
“During an interview with the OIG on January 12, 2022, the provider reported being uncomfortable with the practice of documenting false blood pressures, yet failed to seek assistance,” Dr. Daigh wrote.
The physician also claimed that they believed that no patients were harmed and they sent “everyone” a blood pressure monitor, the report stated. According to the OIG though, in a review of 67 electronic health records out of the 312 patients, those mitigation efforts did not happen for most patients.
The report stated only nine patients already had a blood pressure monitor or had one ordered by the provider.
The OIG also determined that out of the 67 patients whose electronic health records were reviewed, none of them experienced adverse clinical outcomes as a result of the false blood pressures, according to the report.
The OIG alerted facility leaders of the falsification of blood pressures and in January 2022, the chief of staff directed the provider to stop entering false blood pressures and notified Human Resources, the report stated. The physician received additional training but appeared to still have difficulty with the virtual visit template, according to the OIG.
Leadership violated VA policy by not initially reporting the physician to the state licensing board, according to the report.
Facility leaders also claimed that all of the blood pressure entries that were 120/80 were reviewed, but the OIG said it later found that they were not.
“The Acting Chief of Staff was unable to provide rationale as to why all EHRs were not clinically reviewed or amended when asked by the OIG,” Dr. Jaig wrote.
In March 2020, the VA provided guidance to convert many in-person patient visits to virtual visits due to the COVID-19 pandemic.
According to the Centers for Disease Control & Prevention, it is important to get an accurate blood picture reading to help assess risk for heart disease and stroke.
“A reading that says your blood pressure is lower than it actually is may give you a false sense of security about your health,” the CDC website stated.
The 8 News Now Investigators reached out to a spokesman to ask whether patients were notified about the falsified blood pressure readings. In an email, the spokesman replied that they were not.
“Due to the fact that all records in question were reviewed by VASNHS with no adverse clinical outcomes, and an addendum was placed all in affected medical records, no institutional disclosures or formal notifications to patients were required or completed outside the medical records update,” Chief of Communication & Customer Experience Charles Ramey wrote.
The VA did eventually report the physician, according to Ramey.
“Based upon the practice of documenting erroneous blood pressures, VASNHS reported the provider to the State Licensing Board as VASNHS does not consider this an acceptable documentation practice,” he wrote.
Ramey provided a list of additional steps taken including training and observation of the physician, administrative actions such as a direct order to cease and desist the falsification of the blood pressure results, a review of medical records, the physician and Chief of Primary Care meeting weekly, and addendums placed in the affected medical records with erroneous blood pressures.
Do you believe you are a patient who was affected? Email investigative reporter Vanessa Murphy: firstname.lastname@example.org.