Failure to Complete Ordered Laboratory Tests for Resident
Penalty
Summary
The facility failed to follow a physician's order dated 8/26/2025 to obtain laboratory tests for one resident. The resident, who had a history of traumatic subarachnoid hemorrhage with loss of consciousness, a gastrostomy tube, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for most activities of daily living. The physician's order required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and magnesium level to be performed. However, review of records and interviews with staff confirmed that these laboratory tests were not completed as ordered. Further investigation revealed that the requisition slip for the lab tests was folded, indicating that the phlebotomist did not collect the required blood samples. Staff interviews confirmed that the missed laboratory tests were not communicated to the physician. The facility's policy required staff to process test requisitions and arrange for tests as ordered by the physician, but this protocol was not followed in this instance.