Failure to Complete Ordered Labs and Notify Physician for Resident With Gross Hematuria
Penalty
Summary
Facility staff failed to obtain ordered laboratory tests and notify the physician of missing results for a resident with new-onset gross hematuria. A telemedicine eye health note documented that the resident, who was on Eliquis and had a history of two recent hospitalizations for gastrointestinal bleeding, was evaluated for visible blood in the urine. The note referenced recent hemoglobin levels of 8.2 and 10.9, and the assessment/plan identified gross hematuria as an acute, worsening problem. The practitioner ordered that the A.M. Eliquis be held if hematuria recurred overnight, a CBC and BMP be checked in the morning, and that a clinician be notified of any change in condition. Review of the resident’s medical record showed no documentation that the CBC ordered on that date was ever completed, that results were obtained, or that the physician was notified about the lack of completed labs. The DON confirmed in an interview that the ordered labs for this resident were never completed and that the physician was not notified. This failure to carry out the physician’s lab order and to communicate about the uncompleted labs constituted the deficiency identified by surveyors.
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