Failure to Follow Up on Missed Lab Tests
Summary
The facility failed to follow up on missed laboratory tests for a resident who had lab tests ordered but not collected. The resident, diagnosed with schizoaffective disorder and having severely impaired cognition, was admitted with a physician's order for several lab tests to be completed on a specific date. However, a review of the laboratory specimen collection log showed no date or time for the collection of these tests, and the laboratory order requisition indicated that the tests were canceled on the scheduled date. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed a lack of awareness regarding the missed lab tests. The Registered Nurse Supervisor stated that if a phlebotomist is unable to draw blood, it should be reported to the charge nurse and documented, but no such documentation was found. The Director of Nursing acknowledged the importance of lab results for monitoring and managing medical conditions, especially for very ill residents, but was unsure why the tests were not completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and severe cognitive impairment did not have physician-ordered laboratory tests completed prior to a scheduled specialist appointment. The omission was confirmed through medical record review, family interviews indicating missed or rescheduled appointments, and verification by the DON.
A resident with multiple medical conditions did not have laboratory tests completed as ordered by the physician, with only a few results present in the record and several missing. The DON and an RN confirmed that required lab results were not available in the medical record, and the physician had not been updated on some findings.
A resident with chronic anemia and low hemoglobin levels experienced delays in obtaining stool samples for occult blood testing. Despite multiple physician orders and the resident having bowel movements, the facility failed to collect and test the samples in a timely manner. Interviews confirmed the delay, which was expected to be completed within two weeks.
The facility failed to ensure that lab tests were completed as per physician orders for three residents. The DON confirmed that the required tests were not conducted at the specified intervals, affecting residents with various medical conditions.
The facility failed to complete ordered laboratory tests for two residents, leading to incorrect and elevated results for one resident's Vancomycin levels and a missed prealbumin test for another resident. Interviews confirmed the lapses in following physician orders.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with multiple chronic conditions, including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. The resident, who had severely impaired cognition, was admitted on 01/15/25 and had a follow-up nephrology appointment scheduled for 07/20/25, with laboratory tests ordered to be completed on 07/14/25. These tests included a complete blood count, hepatic function panel, magnesium, microalbumin/creatinine ratio, renal function panel, sodium, protein/creatinine ratio, and urinalysis. Review of the medical record showed no evidence that the laboratory tests were completed as ordered. Family interviews confirmed that the facility had not completed the ordered tests prior to appointments, resulting in rescheduled or missed appointments. The Director of Nursing verified that the laboratory tests were not completed as ordered.
Failure to Complete and Document Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing for a resident was completed as ordered by the physician. The resident, who had diagnoses including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis, had multiple active laboratory orders for monitoring various conditions and medications. These orders included regular Albumin levels, CBC, BMP, Depakote levels, and other specific tests at weekly, biweekly, monthly, and multi-month intervals. Review of the resident's medical record revealed that many of these laboratory tests were not completed as ordered, with only a few laboratory results present in the record for specific dates. Further review and interviews with the DON and an RN confirmed that several laboratory results were missing from the medical record, and the physician had not been updated on some of the laboratory findings. During the survey, the RN was observed printing some missing results from the laboratory services website, but the DON was unable to provide evidence of other required laboratory testing being completed. This failure to complete and document laboratory testing as ordered constituted the deficiency.
Delayed Laboratory Testing for Occult Blood in Stool
Penalty
Summary
The facility failed to ensure timely laboratory testing for a resident who required stool samples for occult blood testing. The resident, who had a history of peripheral vascular disease, amputations, hypertension, duodenal ulcer, and chronic anemia, was admitted to the facility with low hemoglobin levels. Physician orders for three stool samples were initially made on July 22, 2024, with subsequent orders on August 15, 2024, and September 12, 2024. However, only one test was completed on September 16, 2024, indicating a delay in obtaining the necessary samples. Despite the resident having bowel movements from September 26 to September 29, 2024, there was no evidence that the stool specimens were collected or tested as ordered. Further orders for stool specimens were made on September 30, 2024, and the samples were eventually obtained on October 1 and October 6, 2024. Interviews with the Director of Nursing and the physician confirmed the delay in obtaining the stool samples, which should have been completed within two weeks according to the physician's expectations. This deficiency was investigated under Complaint Numbers OH00158714 and OH00158447.
Failure to Complete Laboratory Tests as Ordered
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as per physician orders for three residents. Resident #10, who has multiple diagnoses including diabetes and chronic pain, had orders for various lab tests to be conducted at specific intervals. However, the last recorded tests were not completed as scheduled, with the most recent tests being conducted in August 2023 and February 2024, missing several required tests. The Director of Nursing (DON) confirmed that the lab tests were not completed as ordered. Resident #26, with diagnoses including hypothyroidism and chronic kidney disease, also had orders for regular lab tests. The review showed that the required tests were not conducted every three months as ordered, with the last BMP drawn in July 2023 and no microalbumin tests documented. The DON verified the failure to complete these tests. Similarly, Resident #17, who has diagnoses including seizures and hyperlipidemia, had orders for lab tests every six months, but the last tests were conducted in August 2023. The DON confirmed that these tests were not completed as ordered.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered for two residents. Resident #271, who had multiple diagnoses including diabetes and amputations, had an order for Vancomycin trough levels to be drawn before the administration of the antibiotic. However, the facility administered Vancomycin before drawing the trough levels on two occasions, leading to incorrect and elevated results. This caused distress to the resident, who subsequently refused further doses of the medication. Resident #64, who had diagnoses including necrotizing fasciitis and acute kidney disease, had an order for a prealbumin level to be drawn by the wound physician. The facility did not complete this laboratory test before the physician canceled the order during a follow-up visit. The physician expected the test to be done when initially ordered and was unaware that the facility had a dietitian following the resident. Interviews with the residents and staff confirmed the lapses in following the physician's orders for laboratory tests. The facility's failure to adhere to these orders resulted in incomplete and inaccurate monitoring of the residents' conditions, as evidenced by the missed and improperly timed laboratory tests.
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