Failure to Obtain Ordered Pro BNP Lab Due to Incomplete Order Processing
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician-ordered Pro BNP laboratory test for a resident with hypertensive heart disease, Stage 5 chronic kidney disease, and heart failure. The order for the Pro BNP test was entered into the electronic medical record by the physician, but the nurse responsible did not edit the order so that it would trigger on the Medication Administration Record (MAR). As a result, the test was not performed, and there was no documentation of the lab result in the resident's record from the date of the order through the review period. The resident was receiving hemodialysis three times a week and was cognitively intact, with no documented acute symptoms of heart failure during this time. Interviews with facility staff, including the Nurse Practitioner, Physician, and Director of Nursing, confirmed that the lab order was missed due to the failure to properly process the order in the electronic system. The process required the nurse to edit the order, print the resident's face sheet, fill out the lab requisition form, and record the order in the lab book, but these steps were not completed. The error was attributed to the nurse who entered the order, who was no longer employed at the facility. The missed lab was not identified in daily clinical meetings because it did not appear on lab reports due to the incomplete order entry.