Deficiency in Laboratory Services and Supplies
Penalty
Summary
The facility failed to ensure an organized system and adequate supplies for timely and accurate laboratory services for four residents. Observations revealed a lack of necessary supplies for in-house blood draws. Resident R1 had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential, but only the CBC was drawn, and the CMP was not completed. Resident R2 had a standing order for potassium level checks, but there was no evidence of these tests being conducted as ordered in December. Resident R3's orders for a CMP and CBC with differential were not fulfilled, and Resident R4's redraw for ACTH and BNP tests was not completed as requested by the laboratory. The Director of Nursing confirmed the deficiencies, attributing them to the absence of an organized laboratory system and insufficient supplies. The facility's laboratory binder contained incomplete order sheets for all four residents, further indicating a lack of proper documentation and follow-through on laboratory orders. These findings highlight the facility's failure to meet the regulatory requirements for providing or obtaining necessary laboratory services to meet the residents' needs.
Plan Of Correction
Twinbrook Healthcare recognizes the importance of timely and accurate laboratory services to meet the needs of our residents. Following identification of the deficiencies cited, immediate corrective actions were taken to address the issues related to lab supply shortages and the organization of laboratory services. The laboratory supply room was promptly restocked to ensure an adequate supply of materials necessary for in-house blood draws. Additionally, nursing staff were re-educated by Director of Nursing (DON)/designee on the process for monitoring and replenishing laboratory supplies, and supply levels will be audited weekly for four [4] weeks and monthly for two [2] months by the Director of Nursing (DON) or designee to ensure availability of necessary items. Regarding the residents cited in the findings, the attending physicians for Residents R1, R2, R3, and R4 were immediately notified of the missed laboratory draws, and the labs were obtained and completed. A thorough audit of all current laboratory orders for facility residents was conducted to ensure compliance, and no further issues were identified. Weekly reviews of lab requests will be conducted via use of electronic medical records generated reports of physician ordered labs three (3) times a week for four [4] weeks, followed by monthly reviews for two [2] months, to confirm that laboratory tests are being ordered, documented, and completed as required. All nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. This education, conducted by the DON or designee, emphasized the importance of adhering to physician orders, maintaining accurate documentation, and ensuring timely completion of all laboratory tests. Education completed by 1/20/2025, and compliance will continue to be reinforced through ongoing education during regular staff in-service sessions. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Finally, it has been verified that no adverse reactions occurred as a result of the missed laboratory draws for the residents cited in this finding. Full implementation of this Plan of Correction will be completed on 1/20/2025.