Failure to Timely Complete Stat Laboratory Orders
Penalty
Summary
The facility failed to ensure that stat laboratory tests ordered for one resident were performed in a timely manner as required by physician orders and facility policy. Specifically, a stat order for CBC, BMP, and urinalysis with culture and sensitivity was placed by the physician, but documentation showed delays in the collection of these samples. The CBC and BMP were collected the following day at 1145 hours, and the urinalysis was collected at 0500 hours, rather than immediately as required for stat orders. There was no evidence in the medical record that the laboratory was contacted promptly to perform the stat tests. Interviews with nursing staff confirmed that the licensed nurse did not collect the urine sample or contact the laboratory right away, and there was no documentation of follow-up or shift-to-shift endorsement regarding the stat laboratory orders. The Director of Nursing acknowledged these findings. The resident involved had the capacity to make medical decisions and was admitted and discharged within the review period. Facility policies required timely provision of laboratory services and proper urine sample collection, but these were not followed in this instance.