Failure to Monitor Lab Results for Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring required laboratory results for an anti-seizure medication. A review of the resident's care plan indicated that lab and diagnostic work should be obtained as ordered and results reported to the physician. The resident had active physician orders for Valproic Acid to be administered daily and a standing order for monthly Depakote (Valproic Acid) level testing. However, there was no documentation of any Depakote lab results in the resident's chart, and the Director of Nursing confirmed that these levels were not drawn during the resident's stay. This lack of monitoring occurred despite the resident's diagnoses, which included traumatic subdural hemorrhage, seizures, altered mental status, and encephalopathy.