Failure to Inform Resident of Lab Draw and Support Self-Determination
Penalty
Summary
The facility failed to inform a cognitively intact resident, who had a diagnosis of type 2 diabetes mellitus, about a physician's order for an A1C laboratory test that required a blood draw. The resident was not notified by staff about the order or the upcoming procedure, and there was no documentation in the electronic medical record (EMR) regarding any discussion with the resident about the lab test or her response. The resident reported being awakened on multiple occasions by laboratory personnel, whom she did not know, attempting to draw her blood without prior notice, leading her to refuse the procedure each time. The resident's roommate confirmed that the resident was upset by these unannounced visits. The Director of Nursing (DON) stated that nursing staff are expected to inform residents of such orders and provide them the opportunity to refuse, as well as document any refusals and notify the physician. However, the DON confirmed that staff failed to document any information regarding the order, the resident's refusal, or any communication with the resident about the blood draw. The laboratory supervisor also confirmed multiple attempts to draw the resident's blood, all of which were refused by the resident. This failure to inform the resident and document the process resulted in the resident not being able to make an informed decision regarding her care.