Failure to Complete Pre-Operative Lab Testing for Surgical Procedure
Penalty
Summary
A deficiency occurred when the facility failed to ensure that pre-operative laboratory testing was completed as ordered for a resident scheduled for surgical procedures to address kidney stones. The resident, who had a history of acute pyelonephritis, hydronephrosis, and kidney stones, was admitted to the facility and subsequently hospitalized for complications related to her condition. Upon return to the facility, she had scheduled urological procedures that required pre-operative urinalysis (U/A) and culture and sensitivity (C&S) testing. The facility received physician orders for U/A and C&S to be completed prior to the resident's scheduled surgeries. However, the medical record lacked evidence that the required labs were completed as ordered before the first scheduled procedure. There were documented issues with entering lab orders into the system, failure to print updated lab requisition sheets, and miscommunication among nursing staff regarding the status of lab orders and specimen collection. As a result, the lab did not accept the collected specimen due to missing documentation, and the required pre-operative testing was not performed in time for the scheduled surgery. Further complications arose when a subsequent urine specimen collected for the rescheduled procedure was found to be contaminated, and there was no evidence that the facility notified the urologist's office or obtained new orders promptly upon receiving the contaminated result. Communication with the urologist's office only occurred shortly before the rescheduled surgery, at which point the procedure was canceled due to the absence of required lab results. The sequence of missed lab collections, documentation errors, and delayed communication led to the resident's surgical procedures being postponed multiple times.