Failure to Provide Ordered STAT Laboratory Services Prior to Resident Discharge
Penalty
Summary
The facility failed to provide laboratory services as ordered for a resident who was admitted with diagnoses including anemia, dysphagia, and cognitive communication deficit. The resident experienced an episode of passing stool with a small amount of bright red blood, prompting the physician to order a fecal occult blood test (FOBT), a complete blood count (CBC), and to hold anticoagulant medications. Initial labs were drawn and reported, revealing low hemoglobin and hematocrit levels. Following these results, the physician ordered a STAT repeat of the hemoglobin and hematocrit (H/H) levels. Despite the STAT order, the laboratory phlebotomist did not arrive to collect the repeat blood samples as required. Facility staff called the laboratory to request the STAT H/H, but there was no documentation of a confirmed timeframe for collection or evidence that the labs were completed prior to the resident's discharge. The Director of Nursing (DON) confirmed that there was no order for the repeat H/H and that the STAT labs were not documented as completed. The facility's policy required that STAT lab orders be called in and expedited, but this process was not followed as intended. The resident was ultimately transferred to a general acute care hospital at the request of the resident and family, with the STAT laboratory tests still pending. The lack of timely completion and documentation of the ordered STAT laboratory tests resulted in a failure to provide necessary laboratory services as ordered by the physician, with the potential for a delay in the resident's care.