Failure to Care Plan for SBE Prophylaxis Prior to Dental Procedures
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and the presence of a heart assist device (LVAD) was not care planned for subacute bacterial endocarditis (SBE) prophylaxis prior to dental procedures. The resident was admitted with significant cardiac risk factors, including an artificial heart pump, which requires prophylactic antibiotics before any dental procedures that may invade the gums, as per standard practice and referenced clinical guidelines. Despite a dental consult recommending dental cleaning and restorative work, there was no evidence in the resident's medical record or care plan that SBE prophylaxis was considered or ordered prior to the scheduled dental appointment. The absence of a comprehensive care plan addressing the need for antibiotic prophylaxis for dental procedures in this high-risk resident constituted a failure to meet professional standards of quality. The findings were reviewed with facility leadership during the exit conference.