Failure to Obtain Ordered Lab Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to obtain ordered laboratory tests for a resident receiving medication that required lab monitoring. The resident had diagnoses including vascular dementia with mood disturbances, anxiety disorder, and depressive episodes, and had a BIMS score of 15/15, indicating the resident was alert and oriented. A physician ordered Depakote sprinkles 125 mg, six capsules by mouth at bedtime for bipolar disorder, and the resident’s care plan identified risk for complications related to psychotropic medications, with interventions including monitoring for side effects and consulting the physician or pharmacist as needed. A subsequent physician’s order directed that a CBC, CMP, and Depakote level be obtained on the next laboratory draw day. Review of the clinical record from the date of the lab order through the survey date showed no documentation that the ordered bloodwork was obtained. The DON stated that routine lab days were Monday, Wednesday, and Friday, and that the resident’s bloodwork should have been drawn on the next scheduled lab day, but she was unable to find documentation that the lab draw occurred. The DON explained that when lab orders are entered into the EHR, the same shift is responsible for confirming the order and writing it in the lab book, and the 11 PM–7 AM shift is responsible for ensuring the order matches what is written in the lab book. The DON was unable to provide documentation that the lab orders were entered into the lab book or explain why the labs were not obtained, and facility policies for physician orders, transcription of orders, and obtaining bloodwork were not provided.
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