Failure to Timely Assess and Follow Up on Lab Orders After Resident Change in Condition
Penalty
Summary
The facility failed to adequately assess a resident and follow up on provider lab orders in a timely manner after a change in condition. A resident with a history of atrial fibrillation, COPD, and dementia, who was on anticoagulant therapy, experienced a decline in condition over several weeks. Despite being at risk for bleeding, the resident was not assessed and charted on daily, and his condition was not closely monitored as required by his care plan. Orders for STAT labs were given after the resident exhibited symptoms such as weakness, moist breath sounds, and passage of black tarry stool, but there was no documentation that these labs were completed or that results were communicated to the provider in a timely manner. The resident's hemoglobin levels were critically low, with a significant drop noted in lab results, but there was a lack of documentation and follow-up regarding these abnormal findings. The contracted NP was not notified of the STAT lab results, and there was confusion among staff regarding lab orders and the process for reporting critical values. The facility's contracted lab did not process the STAT labs as required, and the results were not promptly reported to the facility or the provider. Additionally, there were gaps in documentation of the resident's assessments on multiple days when his condition warranted close monitoring. The DON acknowledged that nurses were responsible for documenting assessments and following up on lab results, but there was no specific facility policy for notifying providers of abnormal lab results. The lack of timely assessment, documentation, and provider notification led to a delay in recognizing the resident's deteriorating condition, ultimately resulting in the resident requiring hospitalization for a gastrointestinal bleed and blood transfusion.