Failure to Notify Provider of Unsuccessful Lab Collection
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner (NP) when ordered laboratory services could not be obtained for a resident. The resident was admitted with diagnoses including diabetes mellitus type II and adult failure to thrive. A physician's order was placed for a comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be collected the following morning. However, when the phlebotomist attempted to collect the blood sample, they were unsuccessful in obtaining a specimen. Nurse #1 stated that it was standard practice for the laboratory to reschedule the collection for the next day and did not notify the NP or Medical Director about the missed lab collection, as the labs were ordered on a routine basis rather than as a stat order. The NP, upon interview, indicated that he was not informed that the labs were not obtained and emphasized that nursing staff should have notified him so he could determine if further interventions were necessary. The Medical Director also stated that the decision to notify would rest with the NP who ordered the labs. The Director of Nursing (DON) and the Administrator both stated that facility protocol was to reschedule lab work if collection was unsuccessful and believed staff followed this protocol. However, the NP clarified to the DON that immediate notification to providers is necessary if labs are delayed or not drawn, especially to ensure proper follow-up. The lack of timely notification to the provider when the labs were not obtained constituted the deficiency identified during the survey.