Failure to Complete Stat Laboratory Orders as Prescribed
Penalty
Summary
The facility failed to ensure that a physician's order for stat laboratory tests, specifically a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP), was completed for one resident. The physician ordered these tests on 9/5/25 at 1315 hours due to the resident's decreased urine output and increased lethargy. However, a review of the resident's medical record did not show any documented evidence that the stat laboratory tests were performed as ordered. Interviews with nursing staff revealed that stat laboratory orders should be processed as soon as possible, typically within two to four hours, and require both entry into the facility's electronic system and direct communication with the laboratory. The laboratory's records confirmed that no stat order was received for the resident, and the last blood work on file was from a previous date. Further interviews with staff indicated that the expected protocol for stat laboratory orders includes notifying the laboratory by phone, documenting follow-up actions, and informing the physician if there are delays. In this case, the nurse who received the order did not see the laboratory technician arrive before the end of the shift, and there was no documentation of follow-up or communication regarding the delay. The Director of Nursing and Administrator acknowledged these findings during the survey.