Failure to Manage Lab Orders and Results
Penalty
Summary
The facility failed to ensure that laboratory orders were properly entered into the electronic medical record and laboratory portal, resulting in incomplete lab tests and delayed notification of abnormal results to providers. This deficiency affected eleven residents, all of whom were sampled in the survey. For instance, one resident experienced serious harm due to unmonitored medication levels and lack of timely consultation, leading to a worsened condition and transfer to a higher level of care. The resident's medication levels were consistently low, and there was no evidence that the physician was notified of these critical results. The facility's Director of Nursing (DON) acknowledged a systemic failure in the lab process, including the lack of a primary person to oversee lab orders and results. Interviews with staff revealed that lab results were often not communicated to providers unless they were critical, and even then, the process was inconsistent. The DON admitted that the facility's process for managing lab orders and results was broken, with no assigned responsibility for ensuring that labs were drawn and results were reviewed and communicated to the appropriate providers. Multiple residents had lab orders that were not completed or documented, and there was no evidence of provider notification for abnormal results. The facility's failure to manage lab orders and results led to residents not receiving necessary medical interventions in a timely manner. The DON and other staff members confirmed that the facility did not have a policy for laboratory processes or for managing changes in residents' conditions, contributing to the deficiencies identified in the survey.
Plan Of Correction
F773 lab services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Resident #5 and #10 no longer reside in facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab process to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, and documentation of physician notification of lab levels and new orders is recorded in the resident clinical record. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur i.e. what quality assurance program will be put into place. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.
Removal Plan
- On the Regional Nurse Consultant educate the Administrator and Director of Nursing on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, lab process with morning meeting process review compared to lab binder by clinical leadership, physician notification of abnormal labs, and follow-up procedures related to laboratory results.
- On the Consultant Physician provide education to facility Medical Director and physician extender on ensuring proper and timely monitoring and treating of residents with -related diagnoses.
- On the Director of Nursing or designee educated 100% of licensed nursing staff on making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
- Process Change: Effective the Director of Nursing is responsible for making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
- On all education and in-service sign-in sheets were reviewed and validated with licensed nursing staff on making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
- On interviews were conducted with licensed nurses across various shifts, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.