Failure to Obtain and Monitor Vancomycin Lab Levels
Penalty
Summary
The facility failed to ensure that blood draw orders for Vancomycin peak and trough levels were obtained and completed for a resident who was receiving intravenous Vancomycin for osteomyelitis. The resident, who had multiple diagnoses including acute osteomyelitis, peripheral vascular disease, diabetes mellitus type two, and abscess of the right ankle and foot, was admitted and received Vancomycin without any corresponding lab orders for monitoring drug levels. Review of the medical record and nursing notes confirmed that no Vancomycin peak or trough levels were ordered or documented during a three-week period of administration. Interviews with facility staff, including an LPN, a physician assistant, the consulting pharmacist, and the Director of Nursing, confirmed that the standard of care for Vancomycin administration was not followed, as regular lab monitoring was expected but not performed. The pharmacist noted that hospital discharge instructions included weekly trough levels, but these were not implemented upon admission. The facility also lacked a policy regarding lab draws and monitoring for antibiotics, contributing to the oversight.