Failure to File Laboratory Reports in Resident Record
Penalty
Summary
A deficiency was identified when it was found that laboratory reports for a resident were not filed in the resident's clinical record as required. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, Bell's palsy, anxiety disorder, and depression, had physician orders for Complete Blood Count (CBC) tests on several occasions. However, no laboratory results for the CBCs ordered on three specific dates could be located in the resident's electronic medical record. During interviews, it was revealed that the facility used two electronic health record (EHR) applications, and the laboratory uploaded results to both. The Medical Records staff only had access to one of these applications and could only file results that were uploaded to the system they could access. The missing laboratory results were uploaded to the EHR application that Medical Records did not have access to, resulting in the reports not being filed in the resident's clinical record.