Failure to Timely Obtain and Communicate Lab Results
Penalty
Summary
The facility failed to obtain physician-ordered cultures in a timely manner for two residents, leading to a deficiency in laboratory services. For the first resident, there was a delay in obtaining and processing a urine analysis (UA) sample, which was ordered due to the resident experiencing increased episodes of discomfort. The UA results were not promptly communicated to the medical nurse practitioner, and there was confusion regarding the completion of a culture and sensitivity test. The resident expressed concern about the delay in receiving results, and the medical nurse practitioner had to follow up to ensure the necessary tests were conducted. For the second resident, there was a failure to complete an ordered ultrasound (US) for a large hematoma observed by the rehabilitation nurse practitioner. The resident, who was unable to turn herself and experienced severe discomfort, did not have the US order documented or completed as expected. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the order and the lack of notification to the physician regarding the resident's condition. The facility's policy and procedures require timely notification of changes in a resident's condition to the attending physician and the resident's representative. However, in these cases, the facility did not adhere to its own standards, resulting in a lack of timely communication and follow-up on critical medical orders. The Director of Nursing confirmed the expectation for orders to be followed and for physicians to be notified of laboratory results, which was not met in these instances.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was discharged on Resident #4 was discharged on On Regional Nurse Consultant re-educated the Director of Nursing on the components of F773 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , DON/Designee completed a quality review of current residents on ensuring physician-ordered cultures are obtained in a timely manner. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , DON/Designee provided education to the licensed nurses on the components of F773 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. Newly hired licensed nurses will be educated by Director of Nurses/Designee on ensuring physician-ordered cultures are obtained in a timely manner. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee to conduct audits of 5 residents 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure physician-ordered cultures are obtained in a timely manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.