Failure to Complete Ordered Laboratory Work and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that ordered laboratory work was completed for a resident with multiple diagnoses, including high blood pressure, atrial fibrillation, respiratory failure, and diabetes. The resident's care plan required diagnostic testing as ordered, and there was a standing order for routine laboratory tests, including a CBC with differential and a comprehensive metabolic panel. On the date of the scheduled lab work, documentation indicated that the laboratory staff were unable to obtain a sufficient blood sample, noting the inability to get a vein and insufficient quantity. However, there was no evidence in the medical record that a follow-up attempt was made to redraw the laboratory tests, nor was there documentation that the physician was notified of the unsuccessful attempt. Interviews with the resident's physician and facility staff confirmed that the expectation was for the lab to be redrawn or for the physician to be notified if the lab work could not be completed. Both unit managers and the DON stated that a new requisition should be entered into the electronic medical record system and that the laboratory service provider was expected to follow up. Despite these expectations and facility policy requiring physician notification of refused or incomplete lab orders, there was no documentation of further action or communication regarding the missed laboratory work.