Failure to Obtain Timely Laboratory Services for Physician-Ordered Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory studies were obtained in a timely manner for three residents with acute medical needs. For one resident with multiple diagnoses including diabetes, hyperkalemia, and heart failure, a STAT order for CBC and BMP was placed following a change in condition. While some specimens were collected promptly, the blood draws for CBC and BMP were delayed until the following day, despite facility policy and staff expectations that STAT labs be collected within two hours. There was no evidence of additional follow-up with the laboratory or notification to the provider regarding the delay, and the provider only became aware of the delay the next morning when the resident's condition had further declined, resulting in a hospital transfer. Another resident with a history of heart failure, hematuria, and urinary tract infection had laboratory orders for respiratory viruses and urinalysis following an acute episode of confusion and foul-smelling urine. The required swabs were not collected on the day of the order due to a lack of supplies, and the tests were performed the following day. The provider was not notified of the delay, nor of the positive influenza result, contrary to facility policy and provider expectations. Interviews revealed that the system for monitoring and ordering lab supplies relied on nurses to notify health unit coordinators when supplies were low, and there was no routine monitoring in place. A third resident admitted for rehabilitation after hip surgery developed fever and cough, prompting orders for respiratory virus testing. While a COVID-19 test was collected and processed, there was no documentation of results for influenza and RSV, and staff interviews indicated uncertainty about specimen storage and lab pick-up procedures. The laboratory confirmed that STAT orders required direct notification from the facility, which did not occur. Facility policies required immediate action for urgent lab orders and a system for maintaining adequate supplies and timely specimen transport, but these procedures were not consistently followed.