Failure to Obtain Ordered Laboratory Services for Multiple Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for three residents. One resident with diagnoses including cerebrovascular disease, hypertension, hypothyroidism, and prediabetes had a physician's order for a Comprehensive Metabolic Panel (CMP) on admission and every three months, but the last CMP was collected several months prior to the review, and there was no care plan addressing lab collection. Another resident with Parkinson's disease, hyperlipidemia, and chronic kidney disease had orders for a CBC and CMP every three months, but these labs were also not collected as ordered, with the last collection occurring months earlier. The care plan for this resident did mention monitoring labs, but the orders were not followed. A third resident, admitted with Parkinson's disease and benign prostatic hyperplasia, had an order for a urinalysis upon admission. Documentation showed repeated notations over several days that the urinalysis was needed, but the specimen was not collected until more than a week after the order. Nursing staff interviews revealed that attempts to collect the specimen were unsuccessful, and alternative collection methods were not pursued. Communication about the outstanding lab order was inconsistent, and the need for the urinalysis was not consistently documented in the 24-hour report. Interviews with nursing leadership indicated confusion regarding lab order discontinuation following a change in medical directors, with some staff believing the orders were no longer active. Leadership also acknowledged that lab collection should have been monitored and communicated more effectively among staff. The facility's policy required the team to process and arrange for lab tests as ordered by the physician, but this was not consistently followed for the residents in question.