Failure to Implement Laboratory Orders for Residents
Penalty
Summary
The facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. Resident 25, who was admitted with acute kidney failure, anemia, severe obesity, and Type 2 diabetes, did not have a complete blood count (CBC), complete metabolic panel (CMP), and Hemoglobin A1C (Hgb A1C) drawn as ordered every three months. This oversight was confirmed during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the tests were not conducted in February, preventing the physician from identifying any potential issues with the resident's blood work. Similarly, Resident 42, who was admitted with Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease, did not have a CMP conducted in September and December as ordered. The resident's care plan emphasized the importance of obtaining and monitoring laboratory work to prevent poor food intake, weight loss, and dehydration. During an interview, the LVN confirmed that the CMP was not done, which could have prevented the doctor from detecting any abnormal results. Resident 100, diagnosed with respiratory failure, epilepsy, and polycystic kidney disease, was supposed to have monthly Keppra level blood draws to monitor therapeutic levels and prevent seizures. However, the last recorded draw was in November, with subsequent months missed. A Registered Nurse (RN) confirmed the oversight, acknowledging that the lack of blood draws could worsen the resident's epilepsy disorder. The facility's policy and procedure indicated the responsibility for ensuring timely laboratory services, which was not adhered to in these cases.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 25 and Resident 42 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. On 3/12/25, Resident 100 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on active resident lab orders to ensure all residents are receiving their labs as ordered, unless otherwise refused. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/26/25, the Director of Nursing (DON) in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Laboratory, Diagnostic and Radiology Services," with emphasis on laboratory, diagnostic, and radiology services being provided to meet resident needs and the facility being responsible for the quality and timeliness of services provided by the laboratory. The in-service also included that laboratory services ordered are documented on the 24-hour report or electronic health record, to ensure that services are coordinated, and results are received, with notification of results to the Primary Physician including any refusals. The Medical Records Director will audit residents' lab orders daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving lab draws as ordered, unless otherwise noted by a refusal. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. The measures to prevent recurrence include the same in-service training and ongoing audits as described above. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing laboratory services as ordered for three months or until compliance is met.