Incomplete Documentation of Preoperative Instructions and Anticoagulant Management
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident undergoing coordination with a community provider for a suprapubic catheter procedure. The resident had diagnoses including neuromuscular dysfunction of the bladder, recurrent urinary tract infections, and atrial fibrillation, and was receiving Eliquis 5 mg twice daily per monthly physician orders. A quarterly MDS showed the resident was alert and oriented with a BIMS score of 15/15. On 12/4/25, the 3–11 PM nursing supervisor received a call from the hospital’s Interventional Radiology department with preoperative instructions for a suprapubic tube placement scheduled for 12/11/25. These instructions included required blood work to be obtained and faxed, NPO status after midnight except medications with sips of water, and specific directions to hold Eliquis starting on the morning of 12/9/25 and to restart it after the resident’s return from the procedure. Although the nurse verified these instructions with the provider and entered related orders, she did not document the full preoperative instructions in a narrative note in the clinical record. Subsequent review of the clinical record from 12/4/25 through 12/11/25 showed no documentation of the complete preoperative instructions received on 12/4/25, aside from a 12/5/25 nurse’s note indicating that INR, CBC, and CMP results were faxed to the hospital. A physician’s order dated 12/4/25 directed that Eliquis be held on 12/9/25 and 12/10/25 for procedure preparation. However, the December MAR showed that while both doses of Eliquis were held on 12/9/25, the morning and evening doses on 12/10/25 and the morning dose on 12/11/25 were administered. A consultation report on 12/11/25 documented that the suprapubic catheter replacement was cancelled because Eliquis had been held on 12/9/25 but not on 12/10/25, and that Eliquis needed to be held for 48 hours. The DON stated that licensed nurses are responsible for documenting all communication with community providers, and the facility’s Charting and Documentation policy requires accurate, relevant, and complete documentation of assessments, observations, and services, including communication used to develop the plan of care and measure quality of care. The lack of complete documentation of the preoperative instructions and related communication led to the cited deficiency.
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