Failure to Complete Ordered HbA1c Lab Monitoring for a Resident
Penalty
Summary
The facility failed to follow physician orders for laboratory monitoring for a resident with a primary diagnosis of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. The resident had an order for HbA1c testing to be performed quarterly in January, April, July, and October. Record review showed that the last HbA1c was drawn in March 2024, with no evidence of the test being completed in October 2024 or January 2025 as ordered. Pharmacy progress notes in November 2024 and February 2025 recommended updating HbA1c lab monitoring, but there was no documentation that these recommendations were acted upon. Interviews with the DON and Corporate Compliance Nurse confirmed that the expected process was for labs to be drawn as ordered and for recommendations from pharmacy reviews to be communicated to the physician or nurse practitioner. However, the facility did not have a protocol or policy in place to ensure laboratory monitoring was completed, and the resident was not included on the lab draw lists generated by Clinical Laboratory Services for the relevant months. The facility was unable to provide proof that the required HbA1c tests were performed as ordered.