Failure to Notify Physician of Unsuccessful Lab Draws
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician after unsuccessful attempts to draw blood for ordered laboratory tests. The resident, a 68-year-old female with multiple diagnoses including acute kidney failure, congestive heart failure, anemia, hypertension, and hypothyroidism, was admitted and had physician orders for specific labs to be completed one week post-admission. Documentation shows that staff attempted to draw blood on two separate occasions but were unsuccessful, and the resident subsequently refused further attempts due to repeated failures. Despite the inability to obtain the required laboratory specimens, staff did not notify the charge nurse, DON, or the resident's physician as required by facility policy and the resident's care plan interventions. The physician was not made aware that the labs were not completed and only learned of the issue after the resident had been discharged. The facility's DON confirmed that she was unaware of the failed attempts until after the resident left and acknowledged that there was no system in place to verify lab completion at that time. Interviews and record reviews confirmed that the physician expected to be notified of any issues with obtaining ordered labs so that alternative arrangements could be made. The facility's laboratory services policy also required prompt notification of the ordering practitioner if lab results could not be obtained. The lack of immediate notification resulted in the ordered labs not being completed during the resident's stay.