Failure to Obtain and Document Ordered Laboratory Test
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when the facility failed to obtain a laboratory test as ordered by the physician for one resident. The resident experienced a change in mental status with paranoid delusions, prompting the physician to order a urine analysis (UA) to rule out a possible urinary tract infection. Upon review, there were no documented results for the ordered UA, nor was there any documentation indicating that the resident refused the test. During an interview, the Director of Nursing stated that the UA was not obtained due to resident refusal but was unable to provide any documentation to support this claim. The absence of both the laboratory result and documentation of refusal was confirmed during the survey.