Laboratory Tests Performed Without Proper Physician Order
Penalty
Summary
Facility staff obtained laboratory tests for a resident without a proper physician's order. Specifically, the resident had a physician's order for an international normalized ratio (INR) test to be performed every Monday. However, clinical record review and laboratory reports showed that the INR was obtained on multiple days throughout the week, not just on Mondays as ordered. The electronic medication administration record indicated that the INR was documented as being obtained daily, except for one day, which was inconsistent with the physician's order. The resident involved had diagnoses including cerebral infarction, type 2 diabetes mellitus, and a prosthetic heart valve, and was on anticoagulant therapy. The resident was cognitively intact and confirmed during an interview that blood was drawn for INR testing about three times a week. The DON acknowledged that the INR should only have been obtained on Mondays, as per the physician's order. Facility policy requires laboratory services to be provided only when ordered by an appropriate practitioner.