Failure to Hold Medication and Monitor Labs per Physician Orders
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility with elevated liver transaminase levels and required assistance with personal care. The resident's hospital discharge summary and subsequent physician notes clearly instructed that atorvastatin therapy should be held until liver function tests returned to normal, and that liver enzyme laboratory work should be rechecked in a few weeks. Despite these instructions, the resident continued to receive atorvastatin daily from the time of readmission through several months, as documented in the Medication Administration Records for April, May, June, and July. There was no evidence in the clinical record that laboratory work to monitor liver enzymes was ordered or completed during this period. Interviews with the Director of Nursing confirmed that the expectation was for the medication to be held and for labs to be obtained in accordance with the physician's notes and plan of care. The failure to implement the resident-directed care and treatment as specified in the physician orders and plan of care resulted in the resident receiving medication contrary to medical instructions and without appropriate laboratory monitoring.