Failure to File Laboratory Reports in Medical Record
Penalty
Summary
The facility failed to ensure that clinical laboratory reports were filed into the medical record for one resident who had diagnoses of osteomyelitis and pyelonephritis. After being discharged from the hospital, the resident was ordered to receive weekly bloodwork while on intravenous antibiotics. Although laboratory tests were completed on two occasions, a review of the resident's medical record showed that the laboratory results were not present in the chart, nor was there documentation that the results were faxed to the infectious disease provider. The DON confirmed that the laboratory results from the outside laboratory had not been received or filed in the resident's medical record, contrary to the facility's laboratory services policy, which requires that laboratory reports be dated and filed in the resident's clinical record.