Failure to Perform Ordered Monthly Laboratory Tests
Penalty
Summary
The facility failed to follow physician orders for monthly laboratory testing for a resident with a history of seizures, chronic kidney disease, and diabetes mellitus type 2. The resident was admitted with these diagnoses and had an order for monthly Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Keppra blood level monitoring. Record review revealed that these laboratory tests were not performed for the months of July, August, September, and November, despite the standing orders. During an interview and record review, a Licensed Vocational Nurse confirmed the absence of the required lab results for the specified months and acknowledged the importance of these tests for monitoring the resident's medication levels and kidney function. The facility's policy indicated that physicians should be notified of diagnostic test results, but there was no evidence that the required labs were drawn or results communicated as ordered.