Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
Facility staff failed to obtain timely laboratory services for two residents, resulting in deficiencies in meeting their clinical needs. For one resident with chronic kidney disease, sepsis, and a history of urinary tract infections, a nurse practitioner ordered a urinalysis to evaluate symptoms consistent with a UTI. However, there was no evidence that the urinalysis was obtained as ordered on 4/25/25. The resident continued to experience symptoms, and a new order for a urinalysis was placed four days later, with the test finally collected on 4/29/25. The resident confirmed that no urine sample was collected prior to that date, and the nurse practitioner later stated the original order did not save in the electronic system. For another resident with multiple diagnoses including diabetes, hemiplegia, and mental health conditions, a provider's progress note indicated a plan to order a urinalysis due to increased urination. However, no corresponding order was found in the medical record, and no urinalysis was conducted at that time. The provider later stated she believed she had entered the order, but it did not appear in the system. The resident subsequently developed symptoms of dysuria and abdominal pain, prompting a new urinalysis order, which later confirmed a urinary tract infection. In both cases, the facility's policy required staff to process and arrange for laboratory tests as ordered by providers. The surveyors found that the staff did not follow through with obtaining the necessary laboratory tests in a timely manner, as evidenced by the lack of documentation and delayed testing despite provider orders or documented plans. No additional information or clarification regarding these failures was provided by the facility prior to the survey exit.