Failure to Complete Ordered Vancomycin Trough Laboratory Test
Penalty
Summary
The facility failed to ensure that ordered laboratory tests were completed as required when a vancomycin trough level was not obtained for one resident receiving IV vancomycin for cellulitis. The resident, who had diagnoses including cellulitis, diabetes mellitus, atrial fibrillation, and osteoarthritis and was cognitively intact with a need for moderate assistance with transfers, had a physician’s order dated 1/14/26 for vancomycin 1 gram IV daily. A lab result from the same date showed a vancomycin trough of less than 3.0, and a nurse’s note on 1/15/25 documented that the trough result was communicated to the pharmacy and that the next vancomycin trough should be done on 1/19/26. However, there was no corresponding physician’s order for the follow-up trough in the record and no indication that the trough was completed on 1/19/26. During interview, facility leadership reported that the nurse had filled out a lab requisition for the test but had not entered the order, and the test was not performed. The resident was later discharged to the hospital on 1/20/26 due to abnormal labs.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.