Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of several residents. For four out of fourteen sampled residents, laboratory results for ordered tests were not filed in their medical records. Specifically, one resident with a history of cerebral infarction, hemiplegia, dysphagia, and hypertension had a physician order for a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw, but the results were not present in the medical record. The laboratory results were only provided later upon request. The Administrator confirmed that the process required the DON to upload lab results into the medical record within a week, but this was not done for the resident in question. Additional residents were also affected by this deficiency. One resident with respiratory failure, dementia, and muscle weakness had orders for a Vitamin B12, Folate, and Iron panel, but no results were found in the record. Another resident with diabetes, chronic kidney disease, and a history of traumatic amputation had orders for a Basic Metabolic Panel and magnesium level, but again, no results were present. A fourth resident with intracranial injury, diabetes, and mood disorders had multiple lab orders, including a complete blood count and metabolic panels, with no corresponding results in the medical record. In each case, documentation indicated that labs were ordered and sometimes reviewed, but the actual laboratory reports were missing from the residents' clinical records.