Failure to Complete STAT Laboratory Tests Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of STAT laboratory tests as ordered for one resident. The resident had multiple complex medical conditions, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices without bleeding, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis, and was dependent for most activities of daily living. A physician order dated 11/22/25 at 5:40 p.m. directed STAT laboratory tests, including a CBC, CMP, lipase, and lactate. Text messages reviewed between the NP and the RN Supervisor on the evening of 11/22/25 showed that the NP confirmed the plan to continue IV hydration and complete the STAT labs after being informed that the DON had advised not to transfer the resident to a hospital and instead start IV fluids and STAT labs due to vomiting, pain, and abdominal discomfort. Record review and interview with the RN Supervisor revealed that the STAT labs were not drawn until 8:00 a.m. on 11/23/25, approximately 13 hours after the orders were received, despite the RN Supervisor acknowledging that STAT labs were supposed to be completed within four hours. The lab report confirmed collection at 8:00 a.m., receipt at 10:35 a.m., and reporting at 12:50 p.m. on 11/23/25. The facility’s laboratory services policy stated that when there is a STAT order, staff must immediately call the lab, clearly mark the requisition as STAT, and that the goal is to complete STAT orders within a 4–6 hour timeframe. The delay in obtaining the ordered STAT labs for this resident constituted the cited deficiency.
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