Failure to Complete Physician-Ordered Lab Tests for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement physician-ordered laboratory tests for one resident, specifically a Complete Blood Count (CBC) and Albumin test, which were ordered due to the presence of a pressure ulcer. Review of the resident's records showed that the orders for these tests, dated 12/11/2024, were not carried out, and there were no corresponding laboratory results available. During an interview, a registered nurse confirmed that the tests had not been performed and acknowledged that without these results, the facility would not have information necessary to understand the cause of the resident's pressure ulcers. The resident involved had significant medical conditions, including diabetes, dysphagia, and quadriplegia, and was dependent on staff for activities of daily living such as toileting, bathing, and dressing. The resident also lacked the capacity to make decisions. Facility policy required staff to process test requisitions and arrange for laboratory tests, but this was not followed in this instance, resulting in inadequate monitoring of the resident's health status.