Failure to Provide Timely Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide timely laboratory services for one resident who was admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The resident developed dysuria, and a physician ordered a urinalysis (UA) and culture and sensitivity (C/S) to be completed. The initial urine specimen collected was found to be insufficient, prompting a repeat order for UA and C/S. Although a nurse collected the repeat specimen and placed it in the facility's refrigerator, the laboratory had already made its scheduled pick-up earlier that day. No staff member called the lab to inform them that the specimen was ready, nor did anyone follow up to ensure the specimen was picked up or to obtain the results. The order for the laboratory test subsequently fell off the facility's tracking system, and the resident was discharged without the ordered labs being completed. Interviews with the DON and the nurse involved confirmed that there was no verification of specimen pick-up or follow-up on the test results. The facility's policies required timely completion and reporting of laboratory services, but these procedures were not followed in this instance, resulting in the deficiency.