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F0658
D

Failure to Complete Physician-Ordered Laboratory Tests

San Rafael, California Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet professional standards of nursing care by not completing all laboratory tests as ordered by the physician for one resident. The resident, who was admitted with multiple fractures, diabetes, hypokalemia, hypertension, and atherosclerotic heart disease, had physician orders for several laboratory tests, including norovirus, C. diff, COVID, and a KUB x-ray, due to symptoms of loose stools. While documentation indicated that the orders were noted and supposed to be carried out, the norovirus test was not completed, and there was no laboratory report for this test in the resident's records. Multiple staff interviews confirmed that the norovirus test was not performed, despite being ordered and documented as carried out. Additionally, the resident had a critical low potassium value reported, prompting further orders for potassium and magnesium administration, as well as repeat labs for magnesium and a comprehensive metabolic panel (CMP) in two days. However, the repeat labs were not completed within the ordered timeframe, with documentation showing the order administration was late and required rebooking. The facility's policy requires that physician orders be followed and not discontinued without a physician's directive, but in this case, the ordered labs were not completed as required.

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