Failure to Obtain Ordered Laboratory Test for a Resident
Penalty
Summary
The facility failed to provide laboratory services as ordered by a physician for one resident. Specifically, a physician ordered a comprehensive metabolic panel (CMP) to be obtained for a resident on a specified date, but the blood sample was not collected and there was no documentation explaining why the test was not performed. Interviews with facility staff, including a licensed vocational nurse and the medical record director, confirmed that the CMP was neither completed nor documented, and the result was not available in the resident's medical record. The resident involved had multiple diagnoses, including failure to thrive, dementia, and seizure disorder, and was dependent on staff for all activities of daily living. The facility's policy required staff to process test requisitions and arrange for laboratory tests as ordered by the physician, but this process was not followed in this instance. The deficiency resulted in the resident not receiving laboratory services necessary to determine their medical and diagnostic needs.