Failure to Provide Timely Laboratory Services and Results
Penalty
Summary
The facility failed to maintain a functioning system for obtaining and processing laboratory services, impacting multiple residents. For one resident with diabetes, a history of falls, and a pressure ulcer, laboratory orders were not completed as intended, and critical results such as A1c values were missing from the medical record. The resident was later sent to the emergency department with acute hyperglycemia and infection, and the provider was unaware that insulin had been discontinued. The nurse practitioner who ordered labs was not informed that the orders had been struck out and reported ongoing issues with receiving lab results, despite ordering a significant number of tests. Other residents also experienced delays or failures in laboratory testing. Several lab orders for multiple residents were not drawn or processed, with no documentation that providers were notified of the outstanding labs. In one case, a resident on clozapine had an active order for monthly CBCs, but there was no evidence these were completed. Staff interviews confirmed that there were 30 outstanding lab orders over a two-week period, and the facility lacked a process to ensure timely collection and communication of lab results. The facility's internal tracking system for labs was only accessible by one staff member, who was unavailable, leaving the facility without access to necessary information. Providers reported having to repeatedly reorder labs and follow up with staff to obtain results, often finding that labs were not performed or results were not documented. The facility's policy required nursing staff to coordinate, review, and document lab results, but interviews with leadership confirmed the absence of a process to ensure timely lab services and result documentation.