Failure to Monitor Serum Vitamin D Levels During High-Dose Therapy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not obtaining physician orders to monitor serum laboratory results for a resident receiving high-dose Vitamin D therapy. The resident, who had diagnoses including metabolic encephalopathy, Vitamin D deficiency, cirrhosis of the liver, and dementia, was prescribed Ergocalciferol (Vitamin D) 50,000 IU weekly for an extended period. Despite physician progress notes indicating the need to recheck Vitamin D levels and adjust the dosage accordingly, there were no orders or evidence that serum Vitamin D levels were monitored or obtained during the resident's stay. Interviews with facility staff, including the DON, PNP, Pharmacy Consultant, and Medical Director, confirmed that no serum Vitamin D laboratory levels had been ordered or drawn for the resident. The Pharmacy Consultant was unaware of the ongoing high-dose therapy, and the Medical Director acknowledged that monitoring should have occurred. The lack of monitoring persisted even though the resident was at risk for Vitamin D toxicity due to prolonged high-dose administration.