Delay in STAT Laboratory Collection for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for one of three sampled residents. A resident was admitted with multiple diagnoses, including nontraumatic subarachnoid hemorrhage, cirrhosis of the liver, type 2 diabetes mellitus, and bacteremia. On the day following admission, a physician ordered several STAT laboratory tests at 10:00 a.m., including CBC, BMP, HgbA1C, urinalysis, culture and sensitivity, and two sets of blood cultures. According to facility staff, STAT laboratory tests are expected to be collected within four hours of the order to ensure prompt diagnostic evaluation and care. However, the laboratory tests for this resident were not collected until 6:15 p.m., which was eight hours after the order was placed. The laboratory results were subsequently received and reported later that evening. Both the MDS nurse and the DON confirmed that the collection of the STAT labs did not meet the facility's expected timeframe, as outlined in their policy and contract with the laboratory provider, which require immediate dispatch and prompt return of results for STAT orders.
Plan Of Correction
F 770 LABORATORY SERVICES CFR(s): 483.50(a)(1)(i) IMMEDIATE CORRECTIVE ACTION: The DON and/or her designee conducted a one-on-one in-service education with the licensed nurse on 5/30/25, regarding facility policy STAT orders. The laboratory company provided a clarification of the laboratory policy on 5/26/25, regarding the definition of STAT order which is 4-6 hours and will be presented and reviewed at the next Quality Assessment/Utilization Review Committee Meeting. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents with physician's orders for STAT Laboratory Tests had the potential to be affected by this deficient practice. The MRD randomly reviewed STAT Laboratory Tests in the last five (5) months. Five out of five STAT lab tests/radiology were collected/examined within 4-6 hours. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted an in-service education with licensed nurses on 5/8/25 and 5/23/25, regarding laboratory company's policy on STAT laboratory tests. The MRD will conduct daily audits of STAT laboratory tests for the next three months to ensure that tests were completed timely. A report of the audit will be submitted to the DON for follow-up. The RN Supervisor during each shift will review STAT laboratory tests and follow-up with laboratory personnel to ensure laboratory tests were done timely. The DON and/or her designee will conduct weekly random reviews of five (5) residents with order for STAT laboratory tests to ensure compliance with policy for the next three months. Licensed staff identified with deficient practice will be given a one-on-one in-service education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding random checks by DON and audits by the MRD. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: May 30, 2025 This page intentionally left blank