Inadequate Lab Monitoring and Communication in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff were competent in managing the care of residents, particularly in the areas of laboratory monitoring, following through with orders, processing consultations, and communicating with physicians. This deficiency was evident in the case of a resident who experienced serious harm due to inadequate monitoring of medication levels and failure to obtain a necessary consultation as requested by the provider. The resident was admitted with multiple medical diagnoses, including generalized idiopathic conditions, and required specific medication management. However, the facility did not monitor the resident's medication levels appropriately, leading to a significant medical event that necessitated transfer to a higher level of care. The report highlights multiple instances where the facility's processes for managing laboratory orders and results were inadequate. For several residents, including the one who suffered serious harm, there were repeated failures to notify physicians of critical lab results, to follow up on lab orders, and to ensure that consultations were scheduled and completed. Interviews with staff, including the Director of Nursing (DON), revealed systemic issues in the facility's lab process, such as the lack of a designated person to oversee lab results and ensure follow-up actions were taken. The DON acknowledged that the facility's process for managing labs was broken, leading to missed lab draws and unreported critical results. The deficiency was further compounded by communication breakdowns among staff and between the facility and external providers. Staff interviews indicated confusion and inconsistency in the lab process, with some staff lacking access to the lab portal and others unclear about their responsibilities in managing lab orders and results. The facility's failure to maintain a reliable system for lab management and communication resulted in significant lapses in care for multiple residents, as evidenced by the lack of documentation and follow-up on critical lab results and physician notifications.
Plan Of Correction
F 726 Competent Nurse staffing 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the 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 will you identify other residents having potential to be affected by the same practice and what corrective actions 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 will you make to ensure that the practice does not recur? Director of Nursing/Designee will educate licensed nursing staff on the care of residents with a diagnosis to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, documentation of physician notification of lab levels and new orders is recorded in the resident clinical record, and that consultation orders for or other outside providers are executed appropriately. 4. How the corrective action(s) will monitor to ensure the practice will not recur, i.e., what quality assurance program will be put in place(s); will be accomplished for those residents: Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place and consultation orders for outside providers are completed 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.