Failure to Complete and Process Ordered Laboratory Tests
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were completed and processed for a resident who required ongoing lab monitoring. The facility’s Facility Assessment stated that the facility would employ or contract staff to provide clinical laboratory services. For one resident with a sacral pressure ulcer, diabetes, a tracheostomy with pneumonia risk, enteral feedings, and a leaking gastrostomy tube, multiple labs were ordered over several weeks, including CBCs, CMPs, BMP, CRP, hemoglobin A1C, prealbumin, and sedimentation rate. These orders were documented on the Physician Order Summary across several dates for various clinical indications, such as monitoring a stage 4 pressure ulcer, diabetes, tracheostomy-related pneumonia risk, enteral feedings, and g-tube leakage. Progress notes by the facility nurse practitioner documented that the last available labs were from a prior hospitalization, including a CMP and CBC from the hospital, and specifically noted that an A1C and weekly CBC/CMP ordered for certain dates were not drawn and needed follow-up and reordering. Despite these orders and notations, the resident’s electronic medical record contained no documentation of any lab results being completed or received during either of the resident’s stays at the facility. The Assistant DON confirmed that there were no lab results for the ordered CBC and BMP related to the g-tube leakage and stated that no labs were completed at the facility during the resident’s stay, only at the hospital.
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