Failure to Obtain and Document Ordered Lithium Monitoring Labs Resulting in Resident Harm
Penalty
Summary
Facility staff failed to obtain and document required laboratory monitoring for a resident prescribed lithium for bipolar disorder, as ordered by the psychiatric Nurse Practitioner. Despite multiple physician orders for lithium levels, complete blood counts (CBC), and comprehensive metabolic panels (CMP) over several months, there was no evidence in the medical record that these labs were drawn, attempted, or refused by the resident. Additionally, there was no documentation that the resident’s physician was notified when the ordered lab work was not obtained. The resident’s care plan also lacked specific interventions for monitoring lithium side effects, signs of toxicity, or lab monitoring, despite the known risks associated with lithium therapy. The resident, who had diagnoses including bipolar disorder, depression, PTSD, and mild intellectual disabilities, was cognitively intact and had a history of stable lithium dosing. In the weeks leading up to the incident, staff and aides observed the resident becoming increasingly groggy, sleeping more, and being unsteady, but these changes were attributed to medication adjustments rather than potential toxicity. The resident continued to receive scheduled lithium doses as documented in the Medication Administration Record, with no indication of medication refusal. On the day of the incident, the resident was found unresponsive, with vomiting, incontinence, pale and yellow skin, and low oxygen saturation. Emergency services were called, and the resident was transferred to the hospital. At the hospital, the resident was found to have a critically high lithium level, acute kidney failure, elevated BUN and creatinine, and required intubation and multiple rounds of dialysis. Interviews with facility staff and providers revealed ongoing issues with lab orders not being scheduled or completed, confusion over the electronic medical record system, and a lack of oversight after the departure of the Resident Care Coordinator who previously audited lab completion. The psychiatric Nurse Practitioner and physician both confirmed that labs were ordered and expected to be drawn, and that failure to obtain these labs delayed detection and intervention for lithium toxicity.