Failure to Obtain Lab Tests and Orders for Invasive Procedure
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for one resident and did not secure a physician's order for an invasive procedure to collect a specimen for another resident. For Resident 18, who was cognitively intact and diagnosed with hypothyroidism, the facility did not obtain the required Thyroid Stimulating Hormone (TSH) tests for September and December 2024, as per the physician's orders. This was confirmed by the Director of Nursing during an interview, where it was acknowledged that there was no evidence of the TSH tests being conducted for the specified months. For Resident 84, who had End-Stage Renal Disease and was dependent on hemodialysis, the facility failed to obtain a physician's order for catheterization to collect a urine specimen. Although there was an order to obtain a urine specimen and contact the hospital's laboratory, the progress note indicated that a straight catheterization was attempted without a physician's order. This was confirmed by the Licensed Practical Nurse/Infection Control Preventionist, who acknowledged the absence of a physician's order for the catheterization procedure.
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 #84 did not suffer any adverse effects from the urine being obtained via straight cath. Resident #18 did not suffer any adverse effects from the lab not being obtained and had a Thyroid stimulating hormone (TSH) drawn on 1/3/25 which was within normal limits. To identify other residents with the potential to be affected, the Director of Nursing/designee will review labs for the prior 2 weeks to ensure labs were obtained as ordered and review any that were not with the medical director to see if they need reordered. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place laboratory orders and verify labs were obtained. Education will include obtaining doctors orders for invasive procedures. To monitor and maintain ongoing compliance, laboratory orders will be reviewed weekly x4 and then monthly x2 to ensure labs are obtained when ordered. The check to ensure labs are obtained as ordered is that they are triggered to the Medication Administration Record (MAR) for sign off. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.