Failure to Timely Report and Conduct Laboratory Tests
Penalty
Summary
The facility failed to obtain and report laboratory results in a timely manner for three residents, leading to deficiencies in meeting their medical needs. Resident R72, diagnosed with hyperkalemia, had critical lab values indicating elevated potassium levels on November 29, 2024. However, the physician was not informed of these critical results until December 1, 2024, resulting in the resident being transferred to the hospital for further evaluation and management. Interviews with staff confirmed the delay in notifying the physician about the critical lab values. Resident R204 was admitted with multiple diagnoses, including a urinary tract infection and sepsis. A pharmacist recommended a lab test for urine pH with Methenamine on September 20, 2024, but the physician did not order it until January 8, 2025, and there was no evidence that the test was completed in a timely manner. Additionally, Resident R169, who was prescribed valproic acid for bipolar disorder, had a physician's order for laboratory studies to measure valproic acid levels on December 16, 2024. However, there was no documentation indicating that these studies were completed as ordered, which was confirmed by a registered nurse.
Plan Of Correction
1. R72, R204, and R169 lab reports have been obtained and reported to their individual physician. Notification of the physician was documented in the medical record of each resident. 2. An audit was completed for residents who had labs ordered from 12/1/2024 to 2-6-2025 to assure lab reports have been obtained and reported to the physician. 3. Education was completed with licensed nurses on the procedure for obtaining and reporting residents laboratory results to the resident's physician and documenting as such. 4. The DON/Designee will audit laboratory orders weekly x 4 weeks then monthly x 2 months to assure that resident's laboratory results are obtained and reported to their individual physician. Findings of the audits will be reported to monthly QA x3.