Failure to Obtain Ordered Laboratory Tests for Residents
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered for two residents. For one resident with diagnoses including renal dialysis and atrial fibrillation, the physician ordered an A1C test to be performed every three months, but the required test for February was not completed, with the last available result from November. Staff interviews revealed uncertainty about how the lab was missed and indicated there was no policy in place. For another resident with a seizure diagnosis and a physician's order for monthly Keppra level monitoring over three months, only the first month's lab was completed, with no documentation of the required tests for the following two months. Facility staff confirmed that these labs were not obtained as ordered.