Failure to Obtain Timely Vancomycin Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for a resident with multiple complex diagnoses, including infection and inflammation of an internal hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension. Upon return from the hospital, the resident had discharge orders for intravenous Vancomycin every 12 hours and for Vancomycin levels to be obtained every Monday. The medical record showed that the first dose of Vancomycin was administered on 04/06/25 at 8:00 P.M., but the required Vancomycin level was not obtained until 04/14/25, despite the standing order and pharmacy recommendations to obtain a pre-dose level prior to the fourth dose. Interviews with the facility pharmacist and administrator confirmed that Vancomycin levels should have been drawn prior to the fourth dose for safe dosing and that the pharmacy had communicated this requirement to the facility. The administrator also confirmed that the Vancomycin level was not obtained as ordered, resulting in a delay in laboratory monitoring for the resident. This deficiency was identified during a complaint investigation and affected one of three residents reviewed.