Failure to Obtain and Document Ordered Laboratory Tests
Penalty
Summary
Nursing staff failed to ensure that laboratory tests ordered by the physician were obtained as scheduled for a resident with multiple complex medical conditions, including metabolic encephalopathy, severe protein-calorie malnutrition, anemia, type 2 diabetes mellitus, bipolar disorder, and paranoid disorder. Specifically, orders for CBC, CMP, lipid panel, and Valproic acid to be drawn every six months, as well as Hgb and A1C every three months, were not carried out as required. Review of the resident's electronic clinical record revealed missing lab results for the specified periods, with no documentation to indicate that the labs were either completed or refused by the resident. The Director of Nursing (DON) confirmed that there was no evidence in the record to show that the blood draws were performed or refused, despite the resident's known history of refusing care and becoming combative. Facility policy requires that all physician orders, including labs, be completed as ordered and that refusals be documented. The lack of documentation and failure to obtain the ordered labs resulted in the deficiency cited by surveyors.