Failure to Complete Physician-Ordered Keppra Level Lab Draw
Penalty
Summary
A physician ordered a Keppra (levetiracetam) blood level to be drawn for a resident with chronic kidney disease and epilepsy who had been readmitted to the facility. Review of the resident's electronic health record (EHR) showed that the Keppra level was ordered but not completed, and there were no progress notes indicating that the blood draw had occurred. The resident had no documented seizure activity during this period. The Director of Nursing (DON) confirmed upon review that the Keppra level had not been drawn, attributing the failure to an incorrectly entered order by a nurse. The facility did not have a specific policy for lab or blood draws, but did have a policy for following physician's orders, which was not adhered to in this case. As a result, the physician was unaware that the ordered lab test had not been completed.