Lab Tests Performed Without Physician Order
Penalty
Summary
A failure occurred in the facility when laboratory tests were obtained for a resident without a physician order. The resident, who was readmitted with an abdominal hematoma and had moderate cognitive impairment, was supposed to have CBCs performed every two weeks to monitor her condition, as discussed between the unit manager and the nurse practitioner. However, review of the electronic medical record revealed that no physician orders for these CBCs were entered, even though the laboratory tests were performed as scheduled. Interviews with facility staff indicated that there was confusion regarding responsibility for entering orders into the electronic system, with the nurse practitioner stating she did not have access to enter orders and the unit manager and DON indicating that nurses are responsible if providers do not enter them. Additionally, the facility did not have a policy on laboratory services. This lack of a documented physician order prior to obtaining laboratory tests had the potential to result in unnecessary laboratory testing for residents.