Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain and complete physician-ordered laboratory tests for three residents who required regular monitoring due to complex medical conditions. For one resident with diagnoses including diabetes mellitus, mood disorder, and other chronic illnesses, there was no evidence that Hemoglobin A1C or Depakote levels were completed after early August, nor that a TSH level was completed after early August, despite orders for these labs every three months. Another resident with multiple diagnoses such as acute respiratory failure, CHF, chronic kidney disease, and diabetes had orders for quarterly CBC, CMP, A1C, uric acid, and TSH tests, but none were completed after early June. A third resident with diabetes had a quarterly Hemoglobin A1C order, but no test was completed in September as required. Interviews with the DON and ADON confirmed that the ordered labs were not completed as scheduled and revealed there was no system in place for tracking when labs were due or completed. Additionally, facility leadership confirmed there was no formal lab policy, and staff relied solely on following physician orders without a structured process for ensuring compliance. These failures were identified during the review of medical records and staff interviews, affecting three residents reviewed for laboratory testing.