Failure to Obtain Ordered Laboratory Services Resulting in Resident Harm
Penalty
Summary
The facility failed to obtain physician-ordered laboratory services for one resident, resulting in harm. The resident was admitted with orders for a CBC and BMP to be completed due to ongoing nausea. Documentation showed that the weekend RN supervisor attempted to draw the labs once but was unsuccessful, and there was no evidence of further attempts or that the physician was notified of the failed draw. The Medication Administration Record did not show that the labs were collected or completed, and the care plan required labs to be completed per physician orders with results reported to the physician. Interviews with staff confirmed that after the initial unsuccessful attempt, no additional efforts were made to obtain the labs, and the physician was not informed in a timely manner. As a result of the missed laboratory tests, the resident's condition deteriorated, leading to an emergency hospital admission. Hospital records documented that the resident was found to have profound anemia, hyponatremia, acute renal failure, and sepsis, requiring transfer to the intensive care unit. The resident reported feeling neglected and stated that the facility did not perform the necessary blood tests as ordered by the physician. Staff interviews confirmed that the labs were not obtained on the days following the initial order, and the physician was not kept informed of the ongoing failure to complete the ordered tests.