Failure to Order, Obtain, and Report Laboratory Results as Directed
Penalty
Summary
The facility failed to order and obtain laboratory tests as directed by the physician or nurse practitioner, ensure timely laboratory services, and promptly notify the ordering practitioner of abnormal results for one resident with a change in condition. The resident, who had dementia and required total assistance with activities of daily living, exhibited symptoms including cloudy and discolored urine, increased confusion, and back pain. A nurse practitioner ordered a urine dip and, if positive, further testing, as well as a CBC and CMP. While the urine dip was performed and urine was sent for further analysis, the CBC and CMP were never ordered or resulted. The urinalysis and urine culture, collected on the same day, revealed an abnormal result with a significant presence of E. Coli, but there was no documentation that these abnormal findings were communicated to the physician or nurse practitioner, nor was any treatment initiated for the infection. There was a six-day delay in the laboratory reporting the abnormal urinalysis to the facility, and an additional delay in the facility reporting these results to the physician or nurse practitioner. The abnormal results were only sent to the practitioner the day after they were received by the facility. The facility also lacked a policy or procedure for ordering laboratory tests and reporting abnormal values to the physician. Interviews with the administrator and DON confirmed the absence of such a policy and described inconsistent processes for handling lab orders and results, as well as issues with the contracted laboratory's timeliness.