Failure to Complete Weekly Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were completed as ordered and in a timely manner for one resident following her readmission from the hospital. The resident, an elderly female with multiple diagnoses including chronic heart failure, COPD, diabetes, and a history of falls, was readmitted with discharge orders specifying weekly laboratory tests (CBC with differential, BUN, creatinine, and LFTs) to be faxed to her infectious disease physician. However, after her readmission, the standing order for weekly labs was incorrectly entered as two one-time orders rather than a recurring weekly order. As a result, laboratory tests were only performed on two consecutive weeks and then not again until the infectious disease clinic contacted the facility regarding missing results. Interviews with nursing staff and record review revealed that the error occurred during the transcription of hospital discharge orders into the facility's electronic medical record system. The LPN responsible for the readmission could not recall if new lab orders were received or properly entered, and the DON confirmed that the original standing order was missing from the system. The facility missed scheduled weekly labs for two weeks, and the issue was only identified after an external clinic inquired about the missing results. The facility's job description for nursing staff includes the responsibility to arrange for diagnostic and therapeutic services as ordered by the physician, which was not fulfilled in this instance.