Failure to Obtain and Document Physician-Ordered Labs and Notify Physician of Delays
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) and other laboratory tests for a resident, despite orders being placed. The resident had a history of chronic kidney disease, recurrent UTIs, atrial fibrillation, repeated falls, and cognitive communication deficits. Orders for a UA, CBC, CMP, and magnesium were placed, but the medical record lacked documentation of any attempts to collect the samples or any refusals by the resident prior to a significant change in condition. There was also no evidence that the physician was notified of the inability to obtain the samples or of any refusals. The resident experienced multiple falls and a change in condition over several days, including confusion, disorientation, and eventually unresponsiveness with respiratory distress. Despite these changes, staff did not document attempts to obtain the ordered tests, nor did they notify the physician about the delays or the resident's refusals. Interviews with staff confirmed that while some claimed the resident refused the UA and labs, there was no documentation of these refusals or of physician notification in the medical record. The facility's own policies required timely notification of changes in condition and provision of physician-ordered services, but these were not followed. Ultimately, the resident was sent to the hospital in an unresponsive state with a high fever and was admitted to the ICU for septic syndrome, urosepsis, and other acute conditions. The lack of timely diagnostic testing and failure to notify the physician of the delays or refusals contributed to a delay in care. The facility was unable to provide any results for the ordered tests, and staff interviews revealed inconsistent practices and a lack of adherence to documentation and notification protocols.