Failure to Obtain Timely Laboratory Services for Multiple Residents
Penalty
Summary
The facility failed to provide timely laboratory services for three residents, resulting in significant delays or omissions in obtaining ordered laboratory tests. For one resident with metabolic encephalopathy and acute kidney failure, laboratory tests ordered on 4/17/25 were not completed until 5/13/25, a delay of 25 days. Documentation shows that multiple reminders were issued by the physician to ensure the labs were completed, but the orders were not fulfilled in a timely manner. Interviews with staff, including a nurse practitioner and the DON, confirmed that standard practice is to complete labs on the next scheduled draw day or the same day if ordered stat, but this protocol was not followed in this case. Another resident with vascular dementia and dysphagia had laboratory tests ordered on 5/20/25 that were never completed. A third resident with myopathy and dementia had laboratory orders placed as pending, which resulted in the labs not being obtained. Staff interviews revealed that there were ongoing issues with lab orders being entered as pending, leading to delays. The DON acknowledged awareness of these issues and confirmed that delays had occurred due to orders being placed in pending status, which prevented timely completion of laboratory tests.