Failure to Obtain Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for a resident. The physician's progress note indicated that the resident was experiencing hypotension and dehydration, and intravenous fluids were administered. A repeat basic metabolic panel (BMP) blood test was ordered for the following day. However, the clinical records revealed that the staff did not place an order in the electronic system to draw the lab, and there was no evidence that the lab was obtained or that results were available on the specified date. Subsequently, the resident was observed with weakness, in and out of consciousness, and using abdominal muscles to breathe, leading to a transfer to the hospital at the family's request. The Director of Nursing confirmed that the lab work was not obtained as ordered.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. Resident R1 has been discharged from the center. 2. The DON/Designee conducted a 7-day lookback of physician progress notes on all current residents to ensure that any ordered labs were placed in the electronic system to draw the lab. Any variances were noted on the facility audit tool. 3. Nursing staff were educated by the Director of Nursing/Designee on ensuring that labs get entered into the electronic system to draw the lab. 4. The Director of Nursing/Designee will conduct an audit of 10 physician progress notes for 4 weeks and 10 physician progress notes monthly for 2 months to ensure that ordered labs were entered into the electronic system to draw the lab. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.