Failure to Obtain Timely Digoxin Level per Physician Order
Penalty
Summary
A 79-year-old resident with diagnoses including congestive heart failure and osteoarthritis was admitted to the facility and had an active physician's order for digoxin 125 mcg daily, along with an order for a digoxin level to be obtained every six months. The pharmacist's medication regimen review on 4/3/25 noted that the last digoxin level was obtained on 4/12/24 and recommended that a new level be obtained immediately and then every six months thereafter, due to the medication's narrow therapeutic window. However, a review of the resident's medical record from 4/12/24 to 5/1/25 revealed no evidence that a digoxin level had been obtained or ordered in response to the pharmacist's recommendation. When the surveyor requested documentation of the digoxin level or an order for it, it was discovered that the order was only written after the surveyor's inquiry. Interviews with clinical staff confirmed that the digoxin level had not been ordered as recommended, despite other laboratory recommendations from the same pharmacy review being followed. The DON also confirmed that the last digoxin level was obtained over a year prior and could not explain why the six-month interval order was not followed.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #36 had a Digoxin lab level drawn on 5-13-2025. ELEMENT #2: Identification of Other residents who may have the potential to be affected: All residents residing at the facility that receive Digoxin have the potential to be affected and will be identified through an order listing report. An audit will be completed to validate a lab has been completed as ordered. Any discrepancies identified will be reviewed with the health care provider. ELEMENT #3: Systemic Changes: Licensed Nursing Staff will be reeducated by 5/26/2025 or prior to their next date worked in the case of the leave of absence or vacationing employee, regarding expectations of following a physician order. Education will include a review of pharmacy recommendations and the facilities process of reviewing them with the provider, the process of ordering labs per provider orders based on the recommendation, and ensuring the labs are completed. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will audit medical records with individuals who had pharmacy recommendations to complete labs 3-5 times per week for 4 weeks to verify the labs were completed based on the physician orders. The Director of Health Care Services will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Director of Health Care Service will assume responsibility for attained and sustained compliance.