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F0658
D

Failure to Monitor Serum Vitamin D Levels During High-Dose Therapy

Amherst, Massachusetts Survey Completed on 06-04-2025

Penalty

Fine: $28,915
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

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