Failure to Complete Routine Thyroid Lab Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of thyrotoxicosis received Total T3 laboratory tests every two weeks as ordered by the physician. The resident was admitted with diagnoses including thyrotoxicosis and hypertension, and the care plan specifically indicated that labs would be completed if ordered by the physician. The physician's order summary documented a standing order for routine Total T3 level testing every two weeks due to abnormal thyroid function studies. However, a review of the resident's lab results showed that the Total T3 test was only completed once, with no further testing conducted during the month of April 2025. During an interview and record review, an LVN confirmed that the required T3 level tests were not completed as ordered and acknowledged the purpose of the test was to monitor the resident's thyroid levels. The facility's policy and procedure required staff to process test requisitions and arrange for tests, but this was not followed in this case. As a result, the resident's thyroid function was not monitored according to the physician's orders during the specified period.