Failure to Obtain Ordered Laboratory Test for Medication Monitoring
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident with epilepsy who was maintained on Keppra (Levetiracetam) for seizure management. The physician assistant documented a decline in the resident's status and weight loss, and ordered a Keppra level to be drawn on a specific date. Review of the resident's clinical record and medication administration record showed that while Keppra was administered as ordered, there was no evidence that the Keppra level was drawn as required. The medication administration record indicated the lab order was blocked off, and no laboratory requisition slip was found to confirm the test was performed. Interviews with facility staff revealed that the Keppra level was not drawn because the necessary laboratory requisition had not been completed by the facility. The DON acknowledged that the absence of the lab requisition resulted in the test not being performed, and confirmed that the resident's clinical record did not contain evidence of the required lab draw. This failure to obtain the ordered laboratory test resulted in inadequate monitoring of the resident's medication level.