Failure to Implement Physician's Order for Anticoagulant Hold
Penalty
Summary
A deficiency occurred when a registered nurse failed to implement a physician's order to hold a resident's Eliquis (an anticoagulant) in preparation for a scheduled procedure. The resident, who had diagnoses including depression and atrial fibrillation, was admitted with a physician's order for Eliquis 5 mg every 12 hours. On March 7, 2025, a nursing progress note documented that the Eliquis was to be held starting March 21, 2025, in anticipation of a procedure scheduled for March 24, 2025, and that a new physician's order would be required to resume the medication post-procedure. However, on March 24, 2025, it was documented that the Eliquis had not been held as ordered, resulting in the cancellation and rescheduling of the procedure. The Director of Nursing confirmed that the registered nurse responsible for entering the hold order admitted to mistakenly not saving the order during the entry process. This failure to implement the physician's order as written led directly to the postponement of the resident's scheduled procedure.