Failure to Complete Physician-Ordered Laboratory Tests in a Timely Manner
Penalty
Summary
The facility failed to ensure that physician orders for laboratory work were completed in a timely manner for one resident. The resident, who had diagnoses including cerebral infarction, moderate protein-calorie malnutrition, and encephalopathy, was admitted on 05/15/25 and had intact cognition according to the MDS assessment. On 05/30/25, after an incident where the resident attempted to bite staff, the physician ordered a complete blood count (CBC), comprehensive metabolic panel (CMP), Vitamin D level, Vitamin B12, B-type natriuretic peptide (BNP), and urinalysis with culture and sensitivity. Despite these orders, the laboratory tests and urinalysis were not collected for at least four days, and there was no documentation in the medical record indicating that nursing staff attempted to obtain the samples or that the resident refused the tests. The DON confirmed that the orders remained active and unfulfilled from 05/30/25 through 06/03/25, and that the expectation was for nursing staff to attempt collection the day the order was received and to notify the physician of any refusals. The nurse practitioner who ordered the labs also confirmed she had not received any updates or reports of refusal, and expected prompt completion of the laboratory work.