Failure to Follow Physician Order for Stool Culture in Resident With Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to collect stool specimens for diagnostic testing for a resident who had ongoing diarrhea. The resident was admitted on an unspecified date and nursing progress notes documented that the resident had been experiencing intermittent diarrhea since admission. A physician’s order dated 2/13/25 directed staff to collect stool to rule out C. diff and norovirus. Nursing progress notes on 3/12/25 at 1:25 p.m. stated that the resident was due for a stool culture and C. diff sample to be sent to the lab, but that no bowel movement occurred on the 3 p.m. to 11 p.m. shift and that the sample would need to be collected on the next shift. Subsequent documentation showed that the resident had bowel movements on both shifts on 3/13/25 and again on 3/14/25, as recorded in the Documentation Survey Report V2 for bowel continence. However, there was no further documentation that the ordered stool culture or C. diff sample was ever collected or sent to the lab. During interviews, the DON confirmed that nursing staff did not carry out the physician’s order for the stool culture, and there was no documentation that the physician had canceled or discontinued the order. The facility’s policy on lab and diagnostic test results stated that staff will process test requisitions and arrange for tests, and that concerns about test handling should not prevent timely, clinically appropriate management of a clinical situation.
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