Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to provide laboratory services as ordered by physicians for two residents. For one resident with severe protein-calorie malnutrition and a history of stroke, physician orders required weekly Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) tests every Monday, starting in early January. However, a review of the clinical record for May showed no documented evidence that these labs were obtained as ordered. The unit manager confirmed that the weekly labs were not completed during this period. For another resident admitted with neuromuscular dysfunction of the bladder and hypertension, physician orders specified CBC and CMP testing on a Saturday and then every Monday thereafter. The clinical record did not show evidence that the labs were obtained on the specified dates. The unit manager explained that when labwork is ordered for weekends or holidays, staff must notify the contracted laboratory service, but this was not done. Additionally, routine and non-routine labwork were not properly separated on requisition slips, contributing to the failure to obtain the ordered labs.