Delay in STAT Laboratory Testing for Resident with Change in Condition
Summary
The facility failed to provide timely laboratory services for a resident who was admitted with diagnoses including acute respiratory failure with hypoxia, urinary tract infection, and chronic obstructive pulmonary disease. The resident experienced a change in condition, specifically hematuria, and the physician ordered STAT laboratory tests, including a CBC with differential and a comprehensive metabolic panel. According to facility staff, STAT labs are expected to be collected within four hours of the order. However, the laboratory tests were not collected until the following day, well beyond the expected timeframe for STAT orders. Record review and staff interviews confirmed that the delay in obtaining the STAT laboratory tests was due to the laboratory company not arriving within the required four-hour window. The facility's policy states that clinical laboratory services should be provided to meet the needs of residents, but in this instance, the delay resulted in a failure to provide necessary and timely care and services for the resident.
Penalty
Resources
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A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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