Failure to Obtain Ordered TSH Lab for Resident with Hypothyroidism
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to obtain laboratory studies as ordered by a physician for one resident. The facility's policy required that laboratory services be provided or obtained when ordered by a physician or other qualified practitioner, and that such services meet the needs of residents. For a resident with hypothyroidism, a pharmacy review recommended monitoring of TSH/thyroid panel due to the resident's use of levothyroxine. A physician's order was in place for staff to obtain a TSH level at the next lab draw, and the resident's care plan also indicated that labs should be obtained as ordered. However, when laboratory tests were drawn, the TSH level was not included, and there was no documented evidence that the TSH level was obtained as ordered. This was confirmed by the Director of Nursing during an interview. The failure to obtain the ordered TSH lab for the resident with hypothyroidism constituted noncompliance with both facility policy and regulatory requirements.
Plan Of Correction
The TSH lab (thyroid stimulating hormone) for R3 was completed and results received prior to end of survey. Lab result was reviewed with MD and no adverse impact to the resident as a result of delayed lab test. Re-education will be conducted by the Director of Nursing for all registered Nurses on the need to ensure all ordered TSH labs are written on the lab requisition form. An audit was conducted of all the TSH to ensure all labs were completed as ordered. New process was put in place with a Lab Form being completed on every lab day (Mon, Wed), that includes residents' name, lab testing to be completed, signature of phlebotomist and documentation of Y= Completed, N=Not completed, UTO=Unable to obtain, or refusal and Nurse Signature. The Director of Nursing or designee will audit every Monday and Wednesday for 6 weeks. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.