Failure to Obtain Timely and Accurate Vancomycin Trough Levels
Penalty
Summary
The facility failed to ensure timely and accurate laboratory services for one resident who was receiving intravenous vancomycin for osteomyelitis, discitis, and sepsis. Physician orders required regular monitoring of vancomycin trough levels and other laboratory tests to assess the effectiveness and safety of the antibiotic therapy. Despite these orders, there was no documented evidence that the required vancomycin trough levels were obtained on the specified dates, and the only recorded trough was not performed at the appropriate time relative to the dosing schedule. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that laboratory draws were scheduled on specific days of the week, and there was confusion or lack of clarity regarding the timing of the vancomycin trough draws. The registered nurses were responsible for drawing blood from the resident's peripherally inserted central catheter, but the records did not show that the required labs were completed as ordered. The pharmacy and consultant pharmacist were not contacted with the necessary lab results, and the facility failed to communicate effectively regarding the resident's laboratory needs. The failure to obtain timely and accurate vancomycin trough levels was confirmed through record review and staff interviews. The physician stated that the trough levels should have been drawn every three days and prior to the next scheduled dose, and that delays or missed draws were not acceptable. The lack of appropriate laboratory monitoring was not explained by the staff, and there was no documentation to support that the required tests were performed as ordered.