Failure to Obtain and Document Ordered Blood Draw
Penalty
Summary
The facility failed to ensure that a blood sample was collected from a resident as ordered by the physician. The physician had ordered a complete blood count (CBC), basic metabolic panel (BMP), c-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to be obtained on a specific date. The laboratory service log indicated that the resident refused the blood draw, and this was signed by an LVN. However, during an interview, the resident stated that he was waiting for the blood sample to be collected and was told he had refused, which he denied. There was no documentation in the nursing progress notes to confirm that the resident refused the blood draw, and the LVN stated she did not document a refusal. The registered nurse supervisor confirmed the lack of documentation and stated that such events should be recorded to clarify what occurred. The resident involved had been admitted with diagnoses including osteomyelitis of the cervical region, right ankle and foot, and diabetes mellitus, and required substantial assistance with daily activities. The facility's policies required that laboratory services ordered by a physician be completed in a timely manner and that any deviations, such as a resident refusal, be documented in the nursing notes. The director of nursing also confirmed that refusals should be documented and the physician notified. The failure to document the refusal and to obtain the blood sample as ordered constituted the deficiency.