Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered by a physician for one resident during their stay. The resident, who had diagnoses including intellectual disabilities, pneumonia, and anxiety disorder, was admitted following hospitalization for a left ankle fracture. A physician order was placed for urinalysis (UA) with culture and sensitivity (C&S), complete blood count (CBC), and B-type natriuretic peptide (BNP) testing to rule out infection and monitor health status. However, review of the electronic medical record showed no lab results for these tests, and an interdisciplinary team note indicated no new labs had been completed. The facility's protocol required staff to process test requisitions and arrange for tests, but this was not followed. The deficiency was confirmed through interviews and record review, including an interview with the DON, who acknowledged that the lab draw was missed and the facility was not compliant with its own lab policy during the resident's stay. The issue was identified only after the resident was transferred to the hospital following a fall. The facility's own review confirmed that the required laboratory services were not provided as ordered between the dates in question.