Failure to Accurately Document and Communicate STAT Lab Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurately documented and systematically organized according to accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a physician's order for a STAT urinalysis (UA) and straight catheterization, including the date and time the order was received. The LVN attempted to obtain a urine specimen by straight catheterization twice without success and endorsed the STAT order to the night shift nurse but did not notify the physician of the failed attempts or the resident's continued complaints of pain. The LVN also did not document the order for straight catheterization in the resident's medical record. Upon review of the resident's progress notes and laboratory reports, it was found that the documentation did not reflect the time the physician's order for STAT labs was received, and the Director of Nursing (DON) was unaware that the STAT lab order had been endorsed from shift to shift or that it was received a day before the resident was transferred to the hospital. The lack of proper documentation and communication regarding the physician's orders and the resident's condition contributed to the deficiency identified during the survey.