Failure to Monitor Medication Levels and Communicate Dosage Changes
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice by not conducting routine testing to verify therapeutic levels of a seizure medication for a resident diagnosed with epilepsy. The resident, who was alert, oriented, and capable of making independent decisions, was initially prescribed Depakote at a daily total of 750 mg. However, due to a miscommunication, the dose was incorrectly decreased to 500 mg daily instead of being increased as intended. This error persisted for two weeks before the dose was corrected. Additionally, the facility did not perform routine Depakote level testing after the initial admission test, which was contrary to the care plan that required monitoring of therapeutic levels. Furthermore, the facility failed to inform the physician of a recommended increase in the dose of Risperdal, an antipsychotic medication, for the same resident who was experiencing increased paranoia and aggression. The psychiatrist confirmed that the Depakote dose should not have been changed and that therapeutic levels should be checked every six months. The psychiatrist also confirmed that the recommended increase in Risperdal was not completed, indicating a lapse in communication and adherence to professional standards of practice.
Plan Of Correction
1. On 1/10/2025 the Nurse manager obtained Depakote levels for Resident R46. Medications were at a therapeutic level. Additional Labs will be obtained every 6 months to monitor therapeutic levels. 2. A review of the medical record for Resident R46 identified that there was no physician order to increase Risperdal based on the Psychiatrist's recommendation. Resident R46 remains on the current dose of Risperdal and there is no order to increase. This was verified by the DON on 1/10/2025. 3. On 12/26/2025 the nurse management team completed an audit of all residents receiving Depakote. The nurse management team verified that residents receiving Depakote have laboratory orders in place to monitor therapeutic levels. 4. During morning clinical meeting, the IDT team will review any resident that has an order for Depakote for residents with medications that require routine testing and verify that orders for routine monitoring are present. 5. Education on conducting routine testing to verify therapeutic levels of seizures medication will be presented by the DON/designee to all licensed nursing staff by 1/16/2025. 6. The DON/designee will conduct audits of residents with medications requiring routine monitoring weekly for 4 weeks and monthly for 3 months.