Failure to Provide Timely Laboratory Services and Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide and report timely laboratory services and perform blood glucose monitoring as ordered for several residents. For multiple residents with complex medical conditions, including diabetes, congestive heart failure, and chronic kidney disease, laboratory tests such as Basic Metabolic Panel (BMP), urine microalbumin, creatinine, and Vitamin D levels were not collected or reported within the timeframes specified by provider orders. In several cases, there was no documentation of attempts to collect samples, no notification to providers regarding delays, and no evidence that results were communicated as required by facility policy. For example, one resident's BMP was ordered to be drawn on a specific date but was not collected until several days later, and another resident's urine sample was not collected for over a week after the order was placed, despite repeated requests from the provider. Additionally, the facility failed to perform blood glucose monitoring per provider orders for residents with diabetes. On specific dates, blood glucose checks were not completed as scheduled for multiple residents, and insulin doses were missed as a result. The failure was attributed to the facility running out of blood glucose monitoring strips and not maintaining a backup supply. Despite being aware of the shortage, staff did not notify the provider in a timely manner or pursue alternative means to obtain the necessary supplies, resulting in missed monitoring and medication administration for residents who required frequent blood glucose checks due to their fragile diabetic status. Interviews with facility leadership, including the DON and NP, confirmed that the facility did not follow its own policies regarding laboratory management and diabetes monitoring. There was a lack of documentation regarding efforts to collect samples, communicate delays, or notify providers of issues affecting resident care. The deficiencies affected multiple residents and were confirmed through record reviews, interviews, and the absence of required documentation in the medical records.