Failure to File Laboratory Results in Resident Record
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical record for one resident. Specifically, a resident with multiple diagnoses, including bilateral primary osteoarthritis of the knee, type 1 diabetes mellitus with diabetic polyneuropathy, anxiety disorder, and mood disorder, was admitted and later readmitted to the facility. On a specified date, a physician's assistant ordered a vaginal culture for yeast, trichomonas vaginalis, and sexually transmitted diseases due to a diagnosis of vaginal discharge. Although the order was completed, the laboratory results were not found in the resident's electronic medical record during a review. Interviews with facility staff confirmed that the lab results, which were from an outside facility, had not been requested or uploaded to the resident's record.