Failure to Schedule Ordered Laboratory Testing for Diabetic Resident
Penalty
Summary
The facility failed to provide laboratory services as ordered for one resident who was being monitored for unnecessary medication use. Specifically, a physician had ordered quarterly A1c testing for a resident with Type 2 Diabetes Mellitus and unspecified complications. The resident's medical record showed a history of very high blood sugar readings, and the consultant pharmacist had recommended continued quarterly A1c monitoring. Despite this, review of the resident's records revealed that no pending or future laboratory tests for the A1c level were scheduled, as required by the physician's order. Interviews with nursing staff and the Director of Nursing confirmed that the process for scheduling routine laboratory tests was not followed. The licensed nurse who received the order was responsible for both entering the order into the system and notifying the laboratory, but this was not completed. As a result, there was a potential for the resident's laboratory test to be missed, which could have impacted the resident's physical health and well-being.