Failure to Complete Physician-Ordered Labs as Scheduled
Penalty
Summary
A physician order was placed for a resident to receive a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) every three months. Review of the resident's medical record showed that these laboratory tests were not completed as ordered on the specified date, with the last documented completion occurring several months prior. The care plan for the resident, who had multiple diagnoses including hemiplegia, type II diabetes, depression, and a history of substance abuse, included interventions to obtain lab results as ordered and notify the physician of abnormal values. However, there was no evidence that the required labs were performed as scheduled. Further review revealed that the resident had moderate cognitive impairment and was receiving several medications, including antidepressants, antiplatelets, and anticonvulsants. During interviews, facility leadership confirmed the lapse in completing the ordered labs and were unable to provide a facility policy regarding adherence to physician orders. This deficiency was identified during a complaint investigation and affected one resident among those reviewed for physician orders.