Failure to Provide Physician-Ordered Lab Services
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by the physician. The resident, who had diagnoses including dementia, acute kidney failure, encephalopathy, and cerebrovascular disease, had a physician's order for a Complete Blood Count (CBC) with differential and platelet count to be performed on the 1st and 3rd Monday of each month. Review of the clinical record, laboratory results, and the Medication Administration Record (MAR) revealed inconsistencies and missing documentation of completed lab work during certain months, specifically April and the beginning of June. The MAR indicated that labs were marked as completed on scheduled dates, but the actual lab results were not present in the resident's records for those periods. Interviews with nursing staff and the Director of Nursing confirmed that there was no evidence of the required lab work being performed during the specified time frames, and no rationale was documented for the missed labs. The facility's policy required monitoring of physician's orders for completion, but this was not followed in this case. The deficiency was identified through clinical record review, staff interviews, and policy review, which collectively demonstrated that the resident did not receive lab services as ordered by the physician.