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 a diagnosis that included COVID-19, had an elevated temperature and tested positive for COVID-19. The physician ordered medications, including Paxlovid, to be administered immediately. However, the medication was not initiated until the following day, despite the availability of the drugs in the facility's Emergency Pharmacy Kit. The delay was attributed to the nurse scheduling the first dose for the next morning instead of administering it immediately. Additionally, there was a failure in the process of obtaining and reporting test results. The test results, which indicated increased left hilar opacity, were completed in the morning but were not reported to the physician until late in the evening. The Director of Nursing was unable to explain why the abnormal results were not received or reported in a timely manner, highlighting a lapse in the facility's process for tracking and communicating test results.
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.