Failure to Obtain and Document Ordered Laboratory Results
Penalty
Summary
The facility failed to obtain and document laboratory results as ordered by physicians for two residents. For one resident, a basic metabolic panel (BMP) was drawn as ordered, but there was no evidence in the medical record that the results were obtained, reviewed, or acted upon. The consulting pharmacist noted the missing results during a medication regimen review and requested that the results be obtained and scanned into the electronic health record, but this was not completed. The Director of Nursing (DON) confirmed that the BMP results could not be located in the resident's chart or the laboratory's record system. For another resident, the pharmacist identified the need for a one-time digoxin level test, which the physician approved and ordered. Despite repeated monthly reminders from the pharmacist in subsequent medication regimen reviews, there was no evidence that the digoxin level was obtained or documented as ordered. The only available digoxin level result was from a later date, and the DON was unable to provide evidence that the laboratory service was obtained as initially ordered or that the pharmacist's recommendations were followed.