Delay in Reporting Test Results and Treatment Initiation
Penalty
Summary
The facility failed to provide timely necessary care and services to a resident, as evidenced by a delay in reporting abnormal test results and subsequent delay in treatment. The resident, who was admitted with various diagnoses, was assessed as moderately impaired for skills of daily decision-making and was receiving medications related to COVID-19. The care plan included administering medications as ordered and monitoring for signs of distress. However, the resident exhibited an elevated temperature and tested positive for COVID-19, which was reported to the practitioner, and droplet precautions were implemented. Despite a physician's order for medication to be administered, there was a delay in starting the treatment. The test results indicating increased opacity were completed but not reported to the physician in a timely manner, leading to a delay in initiating the prescribed medication. The Director of Nursing (DON) was unable to explain why the abnormal results were not faxed or received promptly. Additionally, the nurse who received the order scheduled the first dose for the next morning instead of administering it immediately, despite the availability of the medication in the facility's Emergency Pharmacy Kit.
Plan Of Correction
Resident #1 was discharged from the facility on 2.1.2025. All residents with ordered have the potential to be affected. On , an audit was conducted by a Registered Nurse to ensure results were reported to the provider timely. Education by Staff Development Coordinator/Designee to the nurses on the facility protocol for tracking and reporting results. DON/Designee will conduct weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.