|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 7/27/2016
Report Timely: Yes
Type of Occurrence: Neglect
DESCRIPTION OF OCCURRENCE:
On 07/27/16 a male patient in his 40's with a prosthetic heart valve failed to receive prophylactic antibiotics prior to a tooth extraction.
The facility conducted an internal investigation and notified the physician. The patient had a mechanical aortic valve replacement in 2008 due to a congenital defect. He was seen on 07/27/16 in the dental clinic for a routine examination. He complained of a toothache and, upon assessment, was noted to have a broken, abscessed tooth. The clinic schedule allowed for extraction of the abscessed tooth the same day. After successful extraction of the tooth, the patient returned to his treatment unit. As the dentist was completing paperwork, the patient's prosthetic heart valve history, which was previously overlooked, was identified. The dentist wrote a "stat" (urgent) order for the patient to receive antibiotics post-extraction. Due to the patient's prosthetic cardiac valve and risk for infective endocarditis, the use of preventive antibiotics was recommended prior to the procedure and was part of the facility's usual practice. The facility noted the window of effectiveness for preventive antibiotics in such a case was four hours. However, by the time the patient received the medication, closer to five hours had elapsed. The patient was monitored by his medical provider and was showing no signs of adverse effects from the late antibiotic administration. The dentist was counseled regarding the importance of reviewing a patient's history and physical prior to treating. The dentist was also advised to notify a patient's treatment unit if required information was not available in the medical record. The facility noted various factors, including a lack of clear communication, contributed to the occurrence. The facility identified they lacked a consistent method for communicating stat orders for medications not administered in the dental clinic. Also, though the patient's history and physical was dictated, the typed version was not in the medical record and information pertinent to the patient's history was handwritten on the back of a form in the record. The dentist's stat order was identified as poorly written, contributing to the order being overlooked by nursing staff. The facility formulated numerous interventions to address the occurrence failures. The facility also noted they were developing an electronic health record (EHR) with an outside vendor, which was set to go live in February of 2017. The facility planned to incorporate lessons learned from the occurrence investigation into the development of the EHR to help prevent the recurrence of such an event.
The Department reviewed the facility's report and supplemental documentation and found that the facility acted appropriately by reporting the occurrence, notifying the appropriate persons and agencies and conducting an investigation.
The Department will review this occurrence prior to the next survey.
Sent to Facility: 11/7/2016
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 11/22/2016