Failure to Obtain STAT Laboratory Services as Ordered
Penalty
Summary
The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.
Plan Of Correction
Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.