Failure to Implement and Document Preoperative Orders Resulting in Cancelled Surgery
Penalty
Summary
A deficiency occurred when the facility failed to implement and document preoperative orders for a resident scheduled for a craniotomy. The resident, who had severe cognitive impairment and multiple diagnoses including aftercare following nervous system surgery, diabetes, major depression, hypertension, and hyperlipidemia, was on a daily aspirin regimen as a blood thinner. Despite being scheduled for neurosurgery, there were no preoperative orders in the medical record to hold aspirin or provide other specific instructions prior to the procedure. The resident continued to receive aspirin up to the day before surgery. The lack of preoperative instructions was discovered when the resident arrived at the hospital for surgery, and the neurosurgery department identified that aspirin had not been held, placing the resident at high risk for bleeding. As a result, the surgery was cancelled and had to be rescheduled. Interviews with facility staff revealed that the nurse responsible for entering preoperative orders did not document or implement any instructions regarding medication management, nor did they seek clarification from the surgeon when such orders were missing. Facility policy required that changes in care plans and significant events be accurately documented in the resident's medical record. However, the process for receiving, documenting, and acting on preoperative orders was not followed. The Director of Nursing confirmed that the failure to hold aspirin and the absence of preoperative documentation directly led to the cancellation of the resident's surgery.