Failure to Obtain Ordered Follow-Up Dilantin Level
Penalty
Summary
The facility failed to provide timely, ordered laboratory services for a resident receiving Dilantin for seizure prevention. The resident had physician orders dated 09/01/25 for Dilantin 100 mg, one capsule in the morning and two capsules in the evening. A nursing note dated 11/24/25 documented a Dilantin level of 44.4 and that the primary care provider was notified, with a new order to hold Dilantin and redraw labs on Wednesday. Review of the resident’s November 2025 laboratory results showed no documentation that the ordered follow-up lab was obtained. During interviews on 03/04/26, an LPN stated the lab should have been obtained on 11/26/25 and confirmed there was no record it was done, and the DON also stated the lab should have been obtained on that date. This deficiency occurred in the context of a survey sample of five residents reviewed for falls, with the ADON identifying that 70 residents resided in the facility at the time of the survey.
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