Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered for one resident. The medical record review showed that the resident, who had diagnoses including morbid obesity, lymphedema, chronic embolism and thrombosis, and hereditary deficiency of clotting factor, was admitted and later transferred to the hospital, where they expired. The resident's care plan included interventions such as laboratory tests as ordered, particularly urine analysis with culture and sensitivity to rule out urinary tract infections. However, there were two separate orders for urine analysis with culture and sensitivity that were not completed as required. Further review of the electronic medical record revealed no results for the ordered urine analyses, and there was no documentation indicating that the prescribing provider was notified about the missed tests. Additionally, the progress notes and the resident's medical record did not contain any information regarding the facility's failure to obtain the ordered laboratory tests. The DON confirmed during an interview that the laboratory tests were not collected as ordered and that there was no documentation of this failure in the medical record.