Failure to Follow Physician Orders for Medication Holds Prior to Procedure
Penalty
Summary
The facility failed to follow physician orders for a resident who was scheduled for two pacemaker placement procedures. Physician orders directed that specific antiplatelet medications, including aspirin EC and Plavix, be held prior to the procedures. However, a review of the resident's records showed that these medications were not discontinued or held as ordered. As a result, the resident was unable to undergo the scheduled pacemaker placement procedures on the intended dates. The resident involved had diagnoses including metabolic encephalopathy and cerebral ischemia, with a BIMS score indicating severe cognitive impairment. The Director of Nursing (DON) confirmed that the medication was not withheld for the appropriate length of time, which led to the missed procedures. The issue was identified after the second missed procedure, and it was noted that the DON had not been informed of the first missed procedure.