Failure to Obtain and Track STAT Laboratory Orders for a Deteriorating Resident
Penalty
Summary
The facility failed to ensure STAT laboratory services were properly ordered, obtained, and tracked for a resident with significant medical conditions, including prostate cancer, lung cancer, insulin-dependent DM, and GERD. Nursing documentation showed that the resident developed coughing, a small amount of coffee-ground emesis, complaints of feeling drunk, and staggering with ambulation. A CBC was ordered for gastrointestinal upset and vertigo but was not obtained. The following day, the resident continued to experience nausea, vomiting, confusion, dizziness, abdominal pain, and had a pulse of 128 beats per minute. In response, the physician ordered a STAT chest x-ray, STAT abdominal x-ray, and a STAT CBC. The STAT CBC was not completed prior to the resident’s death. The contracted laboratory request daily log showed an electronic order for a CBC, but the DON stated the order did not specify that it was STAT. Confidential interviews indicated staff were aware the resident was ill, with one employee describing vomiting of thick, stringy, coffee-ground-like black material that later became bile, and that STAT labs ordered were supposed to be completed within 8 hours, but the lab technician did not arrive until after the resident had died. Another employee stated that STAT labs meant urgent and should be completed as soon as possible. The DON confirmed that a STAT CBC with differential ordered in the morning was not completed before the resident’s death and was unsure why the labs had not been done. The clinical record lacked documentation that nursing staff called the laboratory when the STAT lab was not performed, and review of the record with the ED and DON confirmed there was no documentation that the STAT CBC was completed. The facility’s Laboratory Services policy stated the facility was responsible for the quality and timeliness of laboratory services but did not define STAT or specify expected timelines for blood draws.
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