Failure to Ensure Timely Laboratory Services and Follow-Up
Penalty
Summary
The facility failed to provide timely laboratory services and appropriate follow-up for a resident who was admitted with diagnoses including cerebral vascular disease, anxiety, and hypertension. The resident developed an elevated temperature and dysuria, prompting a physician order for urinalysis and urine culture and sensitivity. Although the specimen was collected and sent to the laboratory, there was no evidence that the urinalysis results were received or reported to the facility. Subsequently, the laboratory reported conflicting results and requested a new specimen, which was collected and sent, but seven days later, the culture and sensitivity results had still not been completed or reported. The facility did not ensure follow-up with the laboratory regarding the missing results. During this period, the resident's condition worsened, with documentation of increased temperature and feeling unwell. Additional laboratory tests were ordered, including urinalysis, culture and sensitivity, CBC, and CMP. The results received indicated significant infection and impaired kidney function, leading to the initiation of IV fluids and transfer to the hospital for acute kidney injury. At the time of the survey, there was no documentation that the facility had followed up with the laboratory regarding the delayed results, and the Director of Nursing was unable to provide evidence of timely follow-up.