Failure to Obtain Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to follow physician orders by not obtaining ordered laboratory tests for a resident with multiple diagnoses, including diabetes mellitus type 2, chronic kidney disease, COPD, and Parkinson's disease. Record review showed that several laboratory tests, such as prealbumin, hemoglobin A1C, and basic metabolic panels, were ordered by the physician on multiple occasions but were not found in the laboratory portal or the resident's medical record. These tests were intended to monitor the resident's nutritional status, blood sugar control, and kidney function, but there was no documentation that they were completed as ordered. Interviews with the Director of Nursing (DON) confirmed that the laboratory tests could not be located in the records or portal. The DON also reported that the nurse practitioner who placed the orders indicated some were made by accident. The facility had recently changed management, and the DON was unable to clarify why the lab orders were not completed at the time they were ordered. The facility's policy requires that physicians identify and order diagnostic and lab testing based on residents' needs, but this was not followed in this case.