Failure to Complete and Track Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to ensure that laboratory tests were completed as ordered for three residents. For one resident, an APRN ordered a complete metabolic panel (CMP), complete blood count (CBC), and Pro-BNP to monitor persistent bilateral leg edema and shortness of breath. Although the Treatment Administration Record indicated that blood was drawn, there were no results in the clinical record, and the Director of Nursing (DON) and Regional Nurse confirmed the labs were never obtained. Another resident had a practitioner's order for blood work, including a Hemoglobin A1C, but only part of the blood work was collected, and the Hemoglobin A1C was missed. A third resident had a lab order that was not drawn as scheduled, requiring the labs to be reordered and rescheduled. The facility's process required practitioners and licensed nurses to print laboratory requisitions and place them in a binder for the laboratory technician, who would then collect specimens and document them in a laboratory log. The DON stated that Unit Managers were responsible for ensuring labs were completed and results reported to the physician, using daily reports and morning meetings to track orders. However, these processes were not followed, resulting in missed and untracked laboratory tests for the affected residents. An audit revealed additional residents with missing labs during the same period.