Failure to Monitor Lithium Levels as Ordered
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to monitor blood levels of a psychotropic medication, Lithium Carbonate, as ordered by the physician for one resident. The resident had a physician's order for Lithium Carbonate 450 mg twice daily and for lithium levels to be checked every three months, starting from 2/5/2024. The last documented lithium level in the resident's medical record was from 11/5/2024, and as of 5/20/2025, there was no documentation of any subsequent lithium level checks. The Director of Nursing confirmed that the resident had not had their lithium level checked since the last recorded date, despite the standing order and facility policy requiring timely laboratory monitoring.