Failure to Complete and Communicate Physician-Ordered Labs
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed in a timely manner for a resident with multiple diagnoses, including vascular dementia, cerebral infarction, and a history of transient ischemic attack. The resident was prescribed Eliquis, an anticoagulant, and a pharmacy review raised concerns about the appropriateness of the dosage based on the resident's renal function. As a result, a physician ordered a complete metabolic panel, complete blood count, and renal function panel to assess the resident's suitability for the prescribed medication. Despite the order, the laboratory tests were not completed as required. The blood draw was scheduled several days after the order and was not performed because the resident was combative and refused, and no qualified personnel were available to assist. The lab technician did not notify the floor nurse of the unsuccessful attempt, and the nurse did not follow up, notify the physician, or document the missed lab or any reattempts. This sequence of inactions resulted in the ordered labs not being completed or communicated appropriately.