Failure to Obtain Timely Laboratory Monitoring for Medication Management
Penalty
Summary
The facility failed to obtain physician-ordered laboratory studies to ensure therapeutic medication levels for a resident. The resident, who had multiple diagnoses including chronic kidney disease stage four, epilepsy, and other chronic conditions, was prescribed several medications such as levetiracetam (an anticonvulsant), potassium supplement, fluvoxamine (an antidepressant), and diuretics (aldactone and lasix). Physician orders required a complete metabolic panel and levetiracetam level to be performed every six months to monitor medication efficacy and safety. Record review showed that the last complete metabolic panel and levetiracetam level were completed on 09/16/24, with no subsequent laboratory testing found after that date. The DON confirmed that the required laboratory tests, which were due in March, had not been completed as ordered. Facility policy required staff to process test requisitions and arrange for tests to be completed, but this was not followed, resulting in the missed laboratory monitoring for the resident.