Failure to Provide Timely Laboratory Services per Physician Order
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a physician for a resident with significant medical conditions, including bladder cancer, acute kidney failure, and anemia. The physician's order, dated 4/3/2025, required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Vitamin B12, Ferritin, and Iron Panel to be completed on 4/6/2025. However, there was no documented evidence that these laboratory tests were performed on the specified date. Multiple reviews of the laboratory logbook, test request forms, and the resident's progress notes confirmed the absence of documentation indicating that the blood draw was completed or refused by the resident. Observations and interviews revealed that the resident exhibited ongoing symptoms, including dark red urine output in the indwelling catheter and feelings of coldness and weakness. Staff interviews confirmed that the laboratory test request form was not completed, which meant the laboratory personnel did not perform the required blood draw. The delay in obtaining the laboratory results led to a significant drop in the resident's hemoglobin and red blood cell levels, as evidenced by a critically low hemoglobin result of 6.8 g/dL when the test was finally performed on 4/15/2025, nine days after the original order. The lack of timely laboratory testing resulted in a delay in identifying the resident's critical condition, necessitating transfer to an acute care hospital for further management. Staff and medical director interviews acknowledged that if the laboratory order had been carried out as scheduled, an earlier decision regarding hospital transfer could have been made. The facility's failure to follow physician orders and document laboratory services contributed directly to the resident's deteriorating condition and the need for acute intervention.