Failure to Complete Ordered Monthly Ammonia Level Lab Tests
Penalty
Summary
The facility failed to ensure that a laboratory test to check ammonia levels was completed monthly as ordered by the physician for one resident. The resident, who was admitted with diagnoses including bipolar disorder, dementia, and gait abnormalities, was determined to lack the mental capacity to make decisions and had severely impaired cognitive skills, requiring substantial assistance with daily activities. A physician's telephone order was placed for monthly ammonia level checks, but a review of the clinical records revealed that these tests were not completed for the months of March, April, and May. There was no documentation of the laboratory results for these months, and the Minimum Data Set Nurse confirmed that the tests had not been performed and results were unavailable. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician. However, the required monthly ammonia level tests were not conducted, and there was no evidence in the records to indicate that the orders were followed. The Minimum Data Set Nurse acknowledged the omission and stated the importance of monitoring ammonia levels for the resident's medical management.