Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to follow physician orders and obtain required laboratory work for two residents reviewed for unnecessary medication use. For one resident with diagnoses including diabetes, urinary tract infection, and colostomy, the facility did not obtain a Hemoglobin A1C (HgbA1C) test in March as ordered by the physician, despite documentation in the care plan and physician orders specifying the need for quarterly lab monitoring. This resident was also noted to be severely cognitively impaired and receiving hypoglycemic medications. For another resident with multiple diagnoses including malignant neoplasm of the colon, diabetes, vitamin D deficiency, anemia, convulsions, and hypertension, the facility failed to obtain a Creatine Kinase (CK) level and a Prostate-Specific Antigen (PSA) level as ordered for October, and did not obtain a HgbA1C level as ordered for February. The care plan and physician orders for this resident specified the need for these labs at regular intervals, but the medical record did not show evidence that these labs were completed as required. Facility leadership confirmed during interviews that labs should be obtained according to physician orders.