Failure to Provide Ordered Laboratory Services and Notify Medical Staff
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block with pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness, was admitted to the facility. The physician ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be drawn on a specific date. However, there was no documentation that these laboratory tests were ordered or obtained as directed by the physician. Review of the resident's Medication Administration Record (MAR) and interviews with facility staff revealed that the laboratory tests were not completed, and there was no evidence that nursing staff followed up on the missing tests or informed the physician or nurse practitioner of the omission. The nurse practitioner noted in the progress note that the laboratory results were pending, but was not aware that the tests had not been drawn or the reason for the delay. Nursing staff involved in the admission process could not explain why the orders for the CBC and BMP were not processed, and the unit manager and DON confirmed that there was no documentation to support that the tests were ordered or that follow-up occurred. Facility policy required that staff process test requisitions and arrange for laboratory services as ordered by the physician, and that nurses follow up on pending or missing results. In this case, the required laboratory services were not provided, and there was a lack of communication and documentation regarding the failure to obtain the ordered tests and notify the appropriate medical staff.