Failure to Obtain and Communicate Vancomycin Lab Results Leads to Medication Toxicity
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to the administration of Vancomycin. The resident, who had multiple complex medical conditions including cellulitis, chronic ulcers, MRSA, end stage renal disease, and diabetes, was admitted with orders for Vancomycin and required regular laboratory monitoring, including Vancomycin trough levels, to guide dosing and prevent toxicity. Physician orders specified the timing and frequency of these labs, and the pharmacy was to dose Vancomycin based on lab results. However, the facility did not consistently obtain the required Vancomycin trough levels prior to administration, and there were multiple instances where lab draws were missed or not performed as ordered. There was a lack of communication and follow-through among nursing staff, providers, and the pharmacy regarding the missing or delayed lab results. Documentation shows that when lab draws were unsuccessful or not obtained, there was no evidence that the physician or pharmacy was notified in a timely manner. Orders for Vancomycin troughs were sometimes entered incorrectly or not clarified, and some lab orders remained in a pending status and were not transmitted to the lab for collection. The pharmacy continued to dispense Vancomycin without receiving the necessary lab results, and nurses administered the medication without confirming that current trough levels were within the therapeutic range. This led to the resident receiving Vancomycin despite the absence of critical lab monitoring. Ultimately, the resident developed critically high Vancomycin levels, which were only identified after a delayed lab draw. The elevated levels prompted discontinuation of the medication and transfer of the resident to the hospital for further care. Interviews with facility staff, providers, and pharmacy consultants confirmed that there was a breakdown in the process for obtaining, documenting, and communicating lab results, as well as a lack of oversight in ensuring that Vancomycin was administered safely and according to orders.