Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory values were completed as ordered by the physician for two out of three residents reviewed. For one resident with multiple diagnoses including dementia, pressure ulcers, diabetes, and cerebral atherosclerosis, a wound care nurse practitioner ordered several labs (CBC, CMP, albumin, prealbumin, transferrin, and hemoglobin A1c). While the CMP was completed, the other ordered labs were not obtained or on file, as confirmed by the Director of Nursing (DON). Another resident with a history of pseudobulbar affect, stroke, depression, Alzheimer's disease, diabetes, hyperlipidemia, hypertension, anxiety, chronic kidney disease, and other cerebrovascular disease also had several labs ordered (CBC, CMP, TSH, A1c, lipid panel, ferritin, B12, and vitamin D) to be collected on a specified lab day. None of these labs were collected or on file, as verified by the DON. The facility's policy required staff to process test requisitions and arrange for testing, but this was not followed for these residents.