Failure to Complete and Report Lab Tests and COVID-19 Testing for New Admissions
Penalty
Summary
The facility failed to obtain, review, and report laboratory tests as ordered, and did not complete required COVID-19 testing for two newly admitted residents. For one resident with a history of urinary tract infection (UTI) and neuromuscular bladder dysfunction, the facility did not report positive urinalysis and culture results to a provider or implement interventions, despite care plan instructions to monitor and report abnormal lab values. This resident was also not tested for COVID-19 on admission, day two, or day four, as required by physician order and facility policy, even though the resident had signed a COVID-19 testing consent form. The same resident was later transferred to the hospital with symptoms including shortness of breath, cough, and blood in the urostomy and nephrostomy tube, and was diagnosed with both a UTI and COVID-19. Staff interviews confirmed that the required COVID-19 testing was not performed and that the positive UTI lab results were not communicated to a provider or acted upon prior to hospitalization. The Infection Preventionist acknowledged that the lab results were not reviewed until the day the resident was sent to the hospital, and that no provider notification or intervention occurred. A second resident, also newly admitted with a history of UTIs and muscle weakness, had a physician's order for urinalysis and culture that was not completed, and COVID-19 testing on admission and day two was not performed as ordered. This resident later tested positive for COVID-19. Staff and leadership interviews confirmed that physician orders for lab tests and COVID-19 testing were not followed, and that providers were not notified of outstanding or abnormal results. The facility was experiencing a COVID-19 outbreak at the time, with a significant number of residents testing positive.