Failure to Obtain Ordered Laboratory Stool Sample
Penalty
Summary
The facility failed to obtain required laboratory samples for one resident who had an active physician order for a stool sample to complete an IFOBT test for colorectal cancer screening. The resident, admitted with multiple sclerosis and slow transit constipation, had an order for the test starting in November 2024. Interviews revealed that certified nursing assistants (CNAs) were responsible for collecting stool samples when notified by the charge nurse, but one CNA did not recall being informed that a sample was needed for this resident. An LPN stated that collecting the sample was challenging due to the need for three separate samples and was unsure if the need for collection was communicated to CNAs. The LPN Unit Manager expected charge nurses to communicate such orders at the start of each shift, and the Director of Nursing Services (DNS) expected physician orders to be followed in a timely manner or the physician to be notified if not completed. Despite these expectations, the sample was not collected as ordered.