Failure to Monitor Digoxin Levels in Resident Receiving Cardiac Glycoside
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring the resident's use of digoxin, a cardiac glycoside medication. The resident, who had moderate cognitive impairment and multiple medical conditions including heart failure and schizophrenia, had been prescribed digoxin for chronic diastolic congestive heart failure. Despite ongoing daily administration of the medication, there was no evidence in the medical record that a digoxin level had been checked or obtained within the last 12 months. The care plan did not specify how often digoxin levels should be monitored, and the facility was unable to provide documentation of any recent laboratory testing for digoxin levels. Observations and interviews revealed that the resident had experienced chest pain, which staff attributed to heartburn, and that the consulting pharmacist had repeatedly requested digoxin level checks without success. The director of nursing confirmed the absence of digoxin level results in the medical record and acknowledged the need for such monitoring. The facility also failed to provide a policy on medication management and monitoring when requested. These actions and omissions resulted in a lack of appropriate monitoring for potential digoxin toxicity, as required by standard care practices.