Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain necessary laboratory studies as ordered by a physician for Resident R158, who was identified as being at high risk for pressure sore development and had moisture-associated skin damage. Resident R158, diagnosed with obesity, was 68 inches tall and weighed 231 pounds, which is 25% above the ideal body weight. The physician had ordered blood tests to assess the metabolism of albumin and thyroid function on November 13 and 15, 2024. However, there was no documentation in the clinical records to indicate that these tests were completed as ordered. This deficiency was confirmed during an interview with a licensed nurse, Employee E17, on December 19, 2024.
Plan Of Correction
1. On 12/19/2024 the DON assessed Resident R158 and there were no negative outcomes for failure to obtain laboratory studies of blood. 2. On 1/5/2025 and 1/16/2025 the Nurse Manager obtained laboratory studies per physician's order. The results are pending review by attending physician. 3. On 12/26/2024 the nurse management team reviewed lab orders for the last 3 months to verify the completion of lab orders per physician orders. 4. The IDT team will review lab binders during morning clinical meetings to verify the completion of labs request from the previous day. 5. Education on obtaining laboratory studies as ordered by the physician will be presented to the licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits of lab binders weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.