Failure to Complete and Document Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered and that timely laboratory results were provided for six of eight residents reviewed. For one resident admitted with sepsis, multiple labs were ordered twice weekly to monitor their condition, but there were blank entries in the Medication Administration Record (MAR) for several ordered dates, and only one lab was repeated despite a critical magnesium level. Documentation showed the lab did not notify the facility of continued critical results, and the resident was later returned to the hospital due to ongoing abnormal labs and fragile status. Another resident with urinary incontinence had a physician order for a urinalysis (UA) and culture, but the MAR showed no documentation of collection attempts over several days. Progress notes indicated repeated unsuccessful attempts to obtain the sample, and the resident expressed frustration over the delay, stating the test was ordered due to increased hallucinations. For a long-term care resident recently treated for a urinary tract infection, laboratory testing was ordered, but while the record showed the labs were drawn, there were no results or further information documented. Additional residents had laboratory orders that were not completed or documented, including one who was discharged without the required labs being drawn and another with no indication that ordered labs were obtained or processed. Staff interviews revealed confusion and gaps in the lab ordering, collection, and result reporting processes, including issues with documentation, communication with the lab, and lack of a formal lab policy. The Director of Nursing confirmed the absence of a lab policy and acknowledged the need for documentation and follow-up when abnormal labs are received.