Failure to Complete Diagnostic Testing, Report Lab Results, and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that ordered diagnostic testing was completed and that significant laboratory results were reviewed and reported to the practitioner for a resident being treated for a herpes simplex outbreak. Specifically, a genital swab ordered by the nurse practitioner was documented as obtained, but there was no evidence that the swab was processed or that results were received or followed up on. Additionally, a urinalysis with culture and sensitivity (UA C&S) was ordered and resulted in a positive urinary tract infection (UTI), but the results were not reported to a provider until four days after they became available, delaying appropriate treatment. The resident involved had a history of dementia, malignant neoplasm of the colon, and was dependent on staff for activities of daily living, including incontinence care. The care plan identified the resident as being at risk for skin breakdown, with interventions to inspect the skin during care. Despite these risks, the resident experienced worsening genital lesions, swelling, and redness over several months, with multiple assessments and new orders for treatment, but without timely completion or follow-up of diagnostic tests as ordered by the practitioner. Furthermore, the facility did not ensure timely communication with the resident's responsible party regarding changes in condition, new diagnoses, or new medications prescribed. Interviews with staff and the Director of Nursing confirmed that the genital swab was not followed up on, the positive UA results were not promptly reported, and the resident's family was not notified of significant changes in the resident's condition. These failures collectively resulted in delays in treatment and the need for more invasive interventions.