Failure to Obtain Ordered Keppra Level for Resident on Anticonvulsant Therapy
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for a resident with a seizure disorder who was receiving Keppra, an anticonvulsant medication. The resident's care plan and hospice admission orders specified that routine labs were to be discontinued except for the Keppra level, which was to be monitored every three months. Despite these orders, the Keppra level was not obtained for the month of May. Record review showed that the last Keppra level was within therapeutic range in February, and the resident continued to receive Keppra as prescribed. However, a lab requisition to discontinue routine labs did not specify that the Keppra level should continue, leading to the cancellation of all labs, including the required Keppra level. Interviews with facility staff and the lab company revealed a miscommunication regarding which labs were to be discontinued, resulting in the Keppra level not being drawn as ordered. The Director of Nursing (DON) acknowledged that the omission occurred when the lab requisition was filled out and that nursing staff were responsible for ensuring labs were obtained as ordered. The lab company also indicated that both the facility and the lab were responsible for ensuring the correct labs were drawn, and the failure to do so was due to a lack of clarification and follow-up. There was no policy in place at the facility regarding laboratory services.