Failure to Provide Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered by physicians for three residents. These residents had multiple physician orders for diagnostic blood tests, including Complete Metabolic Panel (CMP), Lipid Panel, Glyco-HbA1c, Thyroid Stimulating Hormone (TSH), Complete Blood Count (CBC), Vitamin D, and Iron studies, all scheduled to be drawn on specific dates. Upon review of the residents' electronic medical records, there were no results for these ordered lab tests, indicating that the tests were not completed as required. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and a Licensed Practical Nurse (LPN), revealed that the facility was experiencing ongoing issues with their contracted laboratory service. Staff reported that lab technicians sometimes did not come to the facility as scheduled, and in some cases, only a few lab orders were completed during visits. The facility's EMR system was integrated with the laboratory's system, and staff were responsible for entering lab orders, but despite this, the lab work for the affected residents was not performed. The laboratory's regional manager confirmed that there were no visible orders or completed results for the residents in question. The residents involved had significant medical histories, including diabetes mellitus, vascular dementia, pulmonary emphysema, quadriplegia, cerebral infarction, and paraplegia. The lack of completed laboratory testing was confirmed by both facility staff and the laboratory service, with staff acknowledging that the issue was known and ongoing. The deficiency was limited to the failure to provide ordered diagnostic testing and maintain appropriate documentation in the residents' medical records.