Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of prescribed laboratory services for two residents. For one resident, a urinalysis and culture and sensitivity were ordered on two separate occasions, but the lab did not pick up the specimen on the first occasion. The resident was straight catheterized twice due to the initial failure to collect the specimen. The preliminary results of the urinalysis were eventually reviewed, and new orders for an antibiotic were received. For another resident, a urinalysis was ordered due to recent falls and agitation. Although the sample was obtained and the lab was notified, the specimen was not picked up and was found in the refrigerator the following day. The resident was prophylactically treated for a urinary tract infection, but subsequent urinalysis results indicated that the resident did not have an infection. The Director of Nursing confirmed that the hospital lab is responsible for picking up lab specimens and that staff were unaware when labs were not picked up timely.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #58 did not have any adverse reactions. Resident #120 did not have any adverse reactions. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents from the last 2 weeks who had an order for a Urine Analysis (UA) to ensure it was obtained timely. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place an order for a UA and ensure it is picked up from the lab timely. Lab now has a routine schedule of being at the facility on Monday, Wednesday, Thursday, and Friday, and if it is a STAT then we call them. To monitor and maintain ongoing compliance, the Director of nursing/designee will review orders placed for a UA daily in clinical morning meeting weekly x4 and then monthly x2 to ensure urines are obtained and collected timely. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.