Failure to Obtain and Review Required Lab Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that laboratory results were obtained and reviewed as ordered to monitor for adverse effects of antipsychotic medications for a resident with severe cognitive impairment and diagnoses including dementia, seizure disorder, and schizophrenia. The resident had active orders for clozapine, which requires regular monitoring with a complete blood count (CBC) with differential every 30 days. However, the electronic medical record showed a gap in laboratory results, with the most recent CBC dated 12/27/2024, and no results for February and March 2025, despite the resident no longer being on hospice and the physician's order to continue monthly monitoring. Interviews revealed that the missed laboratory testing was due to staff failure to obtain the resident's blood sample, with the Director of Nursing stating that when staff are too busy or unwilling, the task is not completed and eventually disappears from the task list without being reported. This resulted in the resident not receiving the required monthly laboratory monitoring for two consecutive months while continuing to receive clozapine and other psychotropic medications.