Failure to Follow Physician's Orders for Lab Tests
Penalty
Summary
The facility failed to adhere to physician's orders for laboratory blood draws for three residents, leading to a deficiency in providing appropriate treatment and care. Resident R1, diagnosed with chronic obstructive pulmonary disease, muscle weakness, and respiratory failure, had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential to be drawn on a specific date. However, the CBC was drawn a day late, and there was no evidence that the CMP was drawn at all. Resident R2, with diagnoses including COPD, respiratory failure, and dementia, had a physician's order for routine potassium level checks on specific days of the month, but there was no evidence that these were conducted in December. Similarly, Resident R3, diagnosed with type 2 diabetes, muscle weakness, and lack of coordination, had orders for a CMP and CBC with differential, which were not collected as ordered. The Director of Nursing confirmed these lapses during an interview, indicating a failure to follow physician's orders for laboratory testing.
Plan Of Correction
Twinbrook Healthcare acknowledges the importance of adhering to physician orders to ensure quality care and has taken immediate corrective actions to address the cited deficiencies. Following identification of the missed laboratory draws for Residents R1, R2, and R3, the attending physicians were promptly notified, and new orders for the required laboratory tests were obtained and completed. A review of the clinical records confirmed that no adverse reactions occurred as a result of the missed labs for the residents cited. To ensure ongoing compliance, the Director of Nursing (DON) or designee conducted a full audit of all current lab orders for facility residents to verify that laboratory tests were completed as ordered. No additional issues were identified during the audit. Moving forward, lab requests will be reviewed by way of electronic medical record generated reports of all physician ordered labs three (3) times a week for four (4) weeks and then monthly for two (2) months by the DON or designee to confirm compliance with physician orders. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. In addition, all nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. Education sessions, led by the DON or designee, emphasized the importance of following physician orders for diagnostic testing and maintaining accurate documentation. Education completed by 1/20/2025, and compliance will be reinforced through ongoing training during new staff orientation and regular in-service sessions. These measures have been implemented to ensure adherence to professional standards of practice and the delivery of quality, person-centered care. Full implementation of this Plan of Correction was completed by 1/20/2025.