Failure to Notify PCP and Document Resident Refusal of Blood Tests
Penalty
Summary
The facility failed to notify the primary care physician (PCP) and document when a resident repeatedly refused ordered blood tests. The resident, who had diagnoses including type 2 diabetes, chronic kidney disease, and atrial fibrillation, had multiple blood tests ordered, such as a basic metabolic panel, CBC with differential, iron, and A1C. Laboratory requisitions showed several attempts to obtain blood samples over several days, but there was no documentation in the nursing notes of the resident's refusal, nor were there any results for the ordered tests. Interviews with nursing staff and the director of nursing confirmed that the blood draws were not completed due to the resident's refusals, but the PCP was not informed, and the refusals were not documented as required by facility policy. The policy specified that refusals of care or treatment must be documented with details such as date, time, type of care, resident's response, and notification of the practitioner. These steps were not followed in this case.