Failure to Obtain Physician-Ordered Lithium Level Lab Test
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were obtained for a resident with schizoaffective disorder, bipolar type, who was prescribed lithium. A physician order for admission labs, including a lithium level, was documented, but review of the resident's records and lab order summary showed that the lithium level was neither requested from the lab company nor completed during the resident's stay. An LPN reported not seeing an option to order a lithium level in the lab portal, and the DON was unaware of why the test had not been entered, noting that a staff member mistakenly believed the lithium level would be included in a CBC. The DON also stated that random audits were conducted to ensure labs were obtained as ordered, but the last audit had been conducted over two months prior.