Failure to Complete and Document Ordered Valproic Acid Lab Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests for monitoring an anticonvulsant medication were completed and followed up in a timely manner for one resident. The resident had medical diagnoses including seizures, vascular dementia, and liver disease, and a care plan intervention requiring lab tests for therapeutic monitoring of medication levels per MD orders, with MD notification of subtherapeutic or toxic levels. Hospital discharge instructions directed that a Valproic Acid level be obtained one week after discharge, and subsequent physician orders on multiple dates required Valproic Acid laboratory values. However, the resident’s medical record contained no documentation that these laboratory tests were ever obtained and no lab results were present. From the time of the resident’s hospital discharge through the review period, progress notes contained no documentation of the resident refusing blood draws or of physician notification regarding any refusals. The DON confirmed there were no lab results on file for the resident since several months prior and no documentation of refusals or reasons why the labs were not performed, despite a facility policy requiring that labs be completed per MD order and abnormal or immediate labs be relayed to the physician. An LPN reported that staff had informed her the resident was very combative and that blood specimens could not be obtained, and stated she notified the physician, who instructed staff to continue attempts; however, there was no corresponding documentation of these refusals or follow-up in the record. The facility was still attempting to determine why the ordered labs from December had not been completed.
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