Failure to Follow Pre-Procedure Orders Results in Canceled Biopsies
Penalty
Summary
The facility failed to follow pre-procedure physician orders for a resident scheduled for a bone marrow biopsy, resulting in the procedure being canceled and rescheduled multiple times. The resident, who had diagnoses including heart failure, peripheral vascular disease, and acute respiratory failure, was on anticoagulant therapy and required significant assistance with activities of daily living. After returning from an oncology appointment, the resident had new orders for a bone marrow biopsy, including instructions to be NPO (nothing by mouth) starting at midnight before the procedure and to hold certain medications, such as apixaban and aspirin, prior to the procedure. Despite these orders, the facility did not properly enter the NPO status or medication holds into the Medication Administration Record (MAR), and the resident was served breakfast on the morning of the scheduled procedure. As a result, the bone marrow biopsy was canceled. When the procedure was rescheduled, the facility again failed to hold the resident's anticoagulant and aspirin as instructed, leading to a second cancellation. Documentation confirmed that the resident received the medications on the days they were supposed to be held. Interviews with facility staff revealed that there were delays in uploading important documents into the electronic medical record (EMR), and communication of new orders was primarily verbal. The Director of Nursing confirmed that pre-procedure instructions were not entered into the EMR, and the dietary staff were only verbally informed of NPO orders. The unit manager acknowledged that the process for reviewing and entering new orders after appointments was not completed as required, directly contributing to the failure to follow pre-procedure instructions.