Failure to Obtain Ordered Laboratory Specimen
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one resident. According to the facility's policy for lab and diagnostic testing, the physician orders diagnostic tests, and the staff is responsible for processing test requisitions and arranging for tests. For one resident, a physician's order was placed for a vancomycin trough to be drawn 30 minutes prior to the administration of vancomycin on a specific date. However, a nursing note revealed that the vancomycin trough was missed on the following day, and new orders were subsequently received to have the test drawn. An interview with the Nursing Home Administrator confirmed that the vancomycin trough was not obtained as per the physician's order on the specified date.
Plan Of Correction
1. Resident 37 has been discharged home. 2. A house audit was conducted to review labs ordered and the last draw date to ensure compliance. 3. The lab procurement process was simplified and streamlined to ensure labs have less chance of being missed. Nurses were educated on the revised process. A report will be run each evening for the next day's labs. The clinical team will review in the morning meeting for accuracy. 4. An audit of ordered labs will be done weekly x 4 and then monthly x 2 and reported to the Quality Assurance team for review. The Director of Nursing or designee will monitor.