Failure to Monitor Vitamin Supplement Levels as Ordered
Penalty
Summary
A resident with a history of B group vitamin deficiency and falls was admitted and prescribed daily cyanocobalamin (vitamin B12) and vitamin D3 supplements. The physician's orders included routine monitoring of vitamin D levels every six months and ongoing administration of vitamin B12 for deficiency. However, a review of the clinical record revealed that no vitamin D laboratory results were available for the specified monitoring periods, and no vitamin B12 level had been drawn since the initiation of the order over two years prior. During an interview and record review, the Assistant Director of Nursing confirmed the absence of required vitamin D and B12 laboratory results, despite efforts to locate them. The facility's policy required staff and physicians to evaluate the effectiveness and effects of medications, but this was not followed, as evidenced by the lack of laboratory monitoring for the resident's prescribed supplements. This resulted in inadequate monitoring related to medication management for the resident.