Duplicate Lab Draw Performed Without New Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to prevent an unnecessary, duplicate blood draw for one resident after the original laboratory order had already been completed. The resident was admitted with a diagnosis of a UTI, and an MDS dated 12/4/2025 indicated the resident’s cognition was intact. A physician’s order dated 12/11/2025 directed that a BMP and CBC be drawn, and laboratory records showed the blood was collected on 12/11/2025 at 4:25 a.m., with results reported on 12/12/2025 at 12:43 p.m. Despite this, on 1/12/2026 the phlebotomist drew the resident’s blood again based on the same 12/11/2025 order, without a new physician order. A nursing progress note dated 1/13/2026 documented that when the resident inquired about lab results, staff checked the lab binder and discovered the phlebotomist had mistakenly redrawn the labs on 1/12/2026 using the already-completed 12/11/2025 order. Interviews and document review showed that the facility’s lab requisition handling contributed to the error. The DON explained that lab requisition forms have a white and yellow copy kept in a lab binder; when labs are drawn, the phlebotomist is supposed to remove the white copy and leave the yellow copy to indicate completion, and the yellow copies are not removed monthly but kept until the binder is full. The comprehensive test requisition for the 12/11/2025 labs was later signed and dated by the phlebotomist on 1/12/2026 to indicate another BMP and CBC collection, even though no new requisition existed for that date. The ADON reported that the phlebotomist admitted she did not pay attention to the color of the forms and only looked at the resident’s name, and the phlebotomist stated she saw both a white and yellow copy in the binder and assumed the white copy remained because the resident had previously refused or was unavailable. The phlebotomist also stated she did not clarify the date on the requisition with staff because no one was at the nurse’s station. The facility’s policy on Diagnostic Test Results Notification addressed obtaining and arranging labs when ordered, but the facility could not produce a policy or practice describing the procedure the phlebotomist should follow when conducting blood draws.
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