Failure to Complete Prescribed Lab Services
Penalty
Summary
The facility failed to ensure the timely completion of prescribed laboratory services for a resident, which resulted in a delay in monitoring and managing the resident's elevated potassium levels. The resident, who was admitted with diagnoses including diabetes, heart failure, and morbid obesity, had consistently elevated potassium levels documented over several days. Despite new orders being written for medication to treat hyperkalemia and a repeat Basic Metabolic Panel (BMP) to be conducted, the facility did not collect the BMP as prescribed. During an interview, the corporate nurse confirmed that the BMP lab test was not drawn and could not explain why the nursing staff did not follow up or notify the prescribing practitioner about the missed test. There was no documented evidence of attempts to reobtain the BMP or notify the practitioner of the failure to complete the ordered diagnostic testing. This inaction posed significant risks to the resident's health, as timely monitoring and addressing of elevated potassium levels are crucial.
Plan Of Correction
1. Physician was immediately notified on 12/30/24 of the ordered lab not being drawn as ordered on 11/22/24. NOR for CMP to be drawn on 12/31/24. Same completed. 2. Current residents with ordered labs have been reviewed to ensure labs have been obtained per physician order and completed. 3. DON/designee will re-educate licensed nursing staff were immediately to facility process for requisitioning of physician ordered labs. 4. DON/designee will perform random audits to ensure lab protocols are being followed and reviewed in a timely matter. Audits to be conducted weekly for four weeks and monthly for two months. Audits to be completed and submitted to QAPI for review and recommendations.