Failure to Ensure Timely Lab Result Reporting and Completion
Penalty
Summary
The facility failed to ensure timely receipt and reporting of critical laboratory test results and completion of ordered lab tests for two residents. For one resident with multiple diagnoses including heart failure, renal insufficiency, and diabetes, a critical potassium level was identified, and repeat labs were ordered. However, the results of a subsequent STAT lab were not followed up on or reported to the nurse practitioner as required, and there was no documentation in the resident's record regarding the results or physician notification until several days later. The facility's policy required charge nurses to monitor and ensure timely receipt and reporting of lab results, but this was not followed in this instance. For another resident with a seizure disorder and other conditions, after an unwitnessed fall believed to be related to seizure activity, the care team decided to obtain a Vimpat (seizure medication) level to check for therapeutic range. However, the resident's record did not show that the Vimpat level was ever obtained, and facility staff confirmed that the test was not completed as intended. These failures demonstrate lapses in following through with critical lab monitoring and reporting processes for residents with significant medical needs.