Failure to Complete and Document Stat Laboratory Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus, hypertension, and urinary tract infection, who had moderately impaired cognition, did not receive laboratory tests as ordered by a nurse practitioner via telehealth. The orders for a comprehensive metabolic panel and complete blood count were placed stat to evaluate symptoms of headache, abdominal pain, and chest pain. Although the chest x-ray and urine sample were completed, there was no documented evidence that the blood work was performed, nor was there any explanation in the medical record for why the tests were not completed. Interviews with facility staff, including registered nurses, the physician, the DON, and the administrator, revealed uncertainty about why the laboratory orders were not carried out. Some staff suggested the resident may have refused the blood draw, but there was no documentation to support this. The facility's policy and staff statements indicated that any refusal or inability to complete laboratory orders should be documented in the medical record, but this was not done in this case.