Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident. The resident, who was cognitively impaired and had a diagnosis of dementia, was noted to have a large bowel movement with red staining on the sheets. Following this observation, a physician ordered three stool samples to be collected for immuno-fecal occult blood testing, with instructions to record each collection in the resident's electronic health record and notify the physician if any results were positive. The first stool sample was collected and tested negative for occult blood. However, there was no documented evidence that the remaining two stool samples were collected and tested, as required by the physician's order. This was confirmed by an interview with the Director of Nursing, who acknowledged the lack of documentation for the remaining tests. This failure to follow through with the physician's orders resulted in a deficiency in the facility's laboratory services.
Plan Of Correction
Resident 29 - unable to retroactively address labs not obtained, MD notified. Residents who are ordered labs have the potential to be affected. Director of Nursing completed education to licensed nurses on the process for ordering labs included transcription to medication administration recorded/treatment administration and supplemental documentation (e.g. bowel movements). Monitoring will be captured through auditing lab orders. Audits will be conducted on 4 clinical records weekly for 4 weeks, then 10 clinical records twice monthly for 2 months. Audits will be conducted by the Director of Nursing. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.