Incorrect Transcription of Preoperative Anticoagulant Hold Order Leading to Procedure Cancellation
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and implement preoperative orders to hold an anticoagulant, resulting in the medication being administered too close to a scheduled procedure and the procedure being cancelled. The resident involved had diagnoses including neuromuscular dysfunction of the bladder, recurrent UTIs, and atrial fibrillation, and was alert and oriented with a BIMS score of 15. The resident’s care plan documented an indwelling catheter for neurogenic bladder with monitoring for UTI symptoms. Interventional Radiology staff called the facility with preoperative instructions for a suprapubic tube placement, including required lab work, NPO status after midnight except medications with sips of water, and directions to hold Eliquis starting on a specified morning and to restart it after the procedure. The nurse receiving the call verified the instructions with the provider and entered the orders the same day. A physician’s order was created directing Eliquis to be held for two days as preparation for the suprapubic tube procedure. However, review of the MAR showed that while the morning and evening doses of Eliquis were held on the first designated day, both doses on the second day and the morning dose prior to the procedure were administered. A consultation report documented that the suprapubic catheter replacement was cancelled because Eliquis had not been held for the required 48 hours, and the nurse reported that the medication was held only on the first day. The 3–11 PM RN supervisor later stated she had selected a start date and duration for the hold order but did not confirm the end date or restart time were correct. The DON stated that, although there was no specific policy for licensed nurses to verify order transcription accuracy after entering verbal orders, nursing standards required the RN to ensure the orders were complete and accurate, and that because the preoperative orders were received verbally and not documented in a nurse’s note, a second licensed nurse check on the next shift did not occur. The facility’s Transcription of Orders policy described who may accept and transcribe orders but no separate physician orders policy was provided.
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