Failure to Obtain and Document Physician-Ordered Blood Work
Penalty
Summary
The facility failed to ensure that blood work was obtained as ordered by physicians for two residents. For one resident with diagnoses including pneumonia, respiratory failure, CHF, anemia, generalized edema, and hypocalcemia, a physician's order directed that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) with differential be obtained on a specific date. Review of the clinical record did not show that the blood work was completed or that the resident refused the procedure. A subsequent order for different blood work was later carried out, but the initial order was not addressed. For another resident with alcohol abuse, hypothyroidism, and peripheral vascular disease, a physician's order directed that a BMP and CBC with differential be obtained on a specific date. The clinical record did not indicate that the blood work was completed or refused. Interviews with facility staff confirmed that documentation was lacking for both residents, and the nurse practitioner was unaware that the blood work had not been obtained. Facility policy requires that laboratory services be provided per physician orders, with results documented and communicated appropriately, but this was not followed in these cases.