Failure to Ensure Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for one resident, resulting in missed routine laboratory tests. Specifically, a male resident with a history of seizures, anemia, glaucoma, and high blood pressure did not have his Comprehensive Metabolic Panel (CMP) drawn every six months as ordered, nor were his Phenobarbital and Dilantin levels checked every three months as required by physician orders. Review of the resident's electronic health record showed that the last CMP was drawn in July, and the last Phenobarbital and Dilantin levels were drawn in November, with no subsequent labs documented. Interviews with facility staff revealed that nurses were responsible for entering lab orders into the electronic system, which was accessible to the outside lab company. However, the ADON admitted to being unaware of the missed labs until questioned by the surveyor and acknowledged the absence of an effective lab monitoring system. The facility's policy required that laboratory services meet residents' needs and that results be reported promptly, but these procedures were not followed in this case, leading to the deficiency.