Failure to Complete STAT Diagnostic Orders as Directed
Penalty
Summary
The facility failed to ensure that STAT chest radiology and laboratory orders were completed as ordered by the physician for a resident with multiple complex medical conditions, including immunodeficiency, anemia, diabetes, hypertension, COPD, cancer, and chronic kidney disease. The resident experienced shortness of breath, and both the family and physician requested STAT labs and a chest X-ray. Despite these orders, there was no documented evidence that the STAT X-ray and laboratory tests were performed as required. The DON confirmed during an interview and record review that these orders should have been completed within a couple of hours but were not carried out. Subsequently, the resident's condition worsened, with documented desaturation and altered mental status, leading to a transfer to the emergency department. Facility policy required prompt action for emergency diagnostic orders, but this was not followed in this case. The deficiency was identified through interviews and record reviews, which confirmed the failure to carry out STAT diagnostic orders as instructed by the physician.