Failure to Complete and Report Laboratory and COVID-19 Testing Orders for New Admissions
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to obtain, review, and report laboratory tests as ordered, notify providers of abnormal or missing test results, and complete ordered COVID-19 testing for two of three newly admitted residents reviewed. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, physician orders for a complete blood count (CBC) and complete metabolic panel (CMP) were not transcribed or completed as ordered. Additionally, a urinalysis with culture and sensitivity (UA C&S) was obtained, but the positive results were not reported to a provider, and no interventions were implemented. The resident was not tested for COVID-19 on admission, day two, or day four, despite signed consent and physician orders. The resident was later hospitalized with a UTI and COVID-19 after presenting with shortness of breath, cough, and blood in the urostomy and nephrostomy tube. A second resident, also with a history of UTIs, had a physician order for a UA C&S that was not completed. Laboratory tests, including a CBC, were obtained without a corresponding physician order, and abnormal results were not reported to a provider. This resident also was not tested for COVID-19 on admission or day two as ordered, and subsequently tested positive for COVID-19. Staff interviews confirmed that required laboratory tests and COVID-19 testing were not completed as ordered, and that abnormal results were not communicated to providers. The facility was experiencing a COVID-19 outbreak at the time of the survey, with multiple residents testing positive. Staff, including registered nurses, the infection preventionist, the DON, and the medical director, acknowledged that physician orders were not followed, laboratory results were not reviewed or reported, and COVID-19 testing protocols were not adhered to for new admissions. These failures resulted in delays in care and contributed to the hospitalization of at least one resident.