Failure to Complete and Document Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing for a resident was completed as ordered by the physician. The resident, who had diagnoses including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis, had multiple active laboratory orders for monitoring various conditions and medications. These orders included regular Albumin levels, CBC, BMP, Depakote levels, and other specific tests at weekly, biweekly, monthly, and multi-month intervals. Review of the resident's medical record revealed that many of these laboratory tests were not completed as ordered, with only a few laboratory results present in the record for specific dates. Further review and interviews with the DON and an RN confirmed that several laboratory results were missing from the medical record, and the physician had not been updated on some of the laboratory findings. During the survey, the RN was observed printing some missing results from the laboratory services website, but the DON was unable to provide evidence of other required laboratory testing being completed. This failure to complete and document laboratory testing as ordered constituted the deficiency.