Failure to Provide Timely Laboratory Services and Complete Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to provide timely laboratory services and complete physician orders for a resident with multiple diagnoses, including dementia, traumatic ischemia/rhabdomyolysis, history of falls, and sick sinus syndrome. The resident, who had severely impaired cognition and an activated Power of Attorney for Healthcare, was scheduled for a urology procedure that required a pre-operative history and physical (H&P) and a urine culture. The urology clinic provided orders on 7/7/25, specifying that the H&P be completed within 30 days prior to the procedure and the urine culture be obtained on 7/11/25. The facility's provider completed the H&P on 7/8/25, but the document was not sent to the urology clinic as required. Additionally, nursing staff were unable to obtain the urine sample on the specified date because the resident left the facility that morning. The Director of Nursing confirmed that the facility did not notify the receiving facility about the incomplete order, which was necessary to ensure continuity of care and prevent a delay in the resident's surgical procedure.