Failure to Complete Ordered Laboratory Tests for Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered for a resident who experienced a change in condition. The resident, who had a history of type II diabetes, hypertension, and hyperlipidemia, was admitted to the facility and later reported symptoms of nausea and diarrhea. The attending physician ordered several laboratory tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), A1C, and hepatic panel, to be drawn. Nursing documentation confirmed that these orders were received and that the resident and family were informed. However, the laboratory tests were not completed as ordered, and the orders were subsequently discontinued. An interview with the Administrator confirmed that the laboratory orders were not carried out, and no additional information was provided regarding the reason for the omission. Policy review indicated that nursing staff are responsible for ensuring all needed labs are included on the draw sheet and logged appropriately. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for change in condition.