Failure to Obtain Ordered Laboratory Result for Medication Level
Penalty
Summary
The facility failed to obtain an ordered laboratory result for a medication level for one resident, identified as Resident #61. The facility's policy requires that physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record with the physician and responsible party notified if indicated. Resident #61 was admitted with multiple diagnoses and was prescribed a medication that required monitoring of its levels due to its significant impact on chemistry. The pharmacist consultant, who reviews medications monthly, recommended that the physician order a level for the medication, but the level was not found in the resident's record. The deficiency was identified when the pharmacist, during a review, noted the absence of the medication level in the chart, and the physician subsequently ordered it to be collected. However, the laboratory result for the medication level was not located in the resident's record. This issue was discussed with the Assistant Director of Nursing and the Administrator, highlighting the facility's failure to ensure the timely and accurate acquisition of necessary laboratory results, which is crucial for the safe administration of the medication.
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? On 4.3.25 resident #61 was assessed by licensed nurse, no concerns identified. On 4.18.25 physician orders reviewed for resident #61-labs/ level completed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 4.16.25 a quality review was completed by the Director of Nursing on current residents with lab recommendations ordered per pharmacy recommendations in the last 3 months to ensure reviewed/follow up documentation in place. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (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: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.