Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to follow physician orders for laboratory testing for one resident with diagnoses including diabetes mellitus, hypertension, and hypothyroidism. The resident's care plan and electronic medical record (EMR) included multiple physician orders for A1c and other labs to be completed at specified intervals. Despite these orders, there was no documentation that the required labs were completed after a certain date. The Director of Nursing (DON) confirmed that orders for A1c checks and other labs were not carried out as directed, and this was further corroborated by a review of the EMR and staff interviews. The deficiency was identified through interviews, record reviews, and policy review, which revealed that staff did not consistently enter or complete lab orders in the EMR as required. The DON and Administrator both stated their expectations that staff should enter and complete orders as directed, but the lack of documentation and follow-through resulted in missed laboratory testing for the resident. The facility's policy on medication and treatment orders did not specifically address the requirement to follow physician orders, contributing to the failure to ensure labs were completed as ordered.