Failure to Withhold Antiplatelet Medication Prior to Dental Procedure
Penalty
Summary
The facility failed to withhold an antiplatelet medication, specifically aspirin, as ordered by the Nurse Practitioner prior to a scheduled dental extraction for a resident with diagnoses including heart failure, hypertension, and chronic pain. The physician's order to hold aspirin for three days before the dental procedure was documented on the dental consent form but was not transcribed to the Medication Administration Record (MAR). As a result, nursing staff continued to administer aspirin to the resident from 11/1/24 through 11/6/24, contrary to the order. This oversight led to the cancellation of the scheduled dental extractions, as the dental provider could not proceed while the resident was still taking aspirin. Interviews with facility staff revealed a breakdown in communication and process regarding the handling and transcription of physician orders related to dental procedures. The DON and Administrator stated that the expected process was for the signed dental form to be given to the Unit Manager and then to the assigned nurse for transcription to the MAR, but this did not occur. The Unit Manager reported not receiving the relevant dental notes or forms. The resident did not report pain at the time of the missed extraction, but later developed a gum abscess requiring antibiotics and eventually underwent extractions after the medication issue was resolved.