Failure to Obtain Timely Sodium Lab Draw After ER Discharge
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident who required follow-up sodium testing after an emergency room (ER) visit for constipation. During the ER visit, the resident’s sodium level was found to be moderately low at 125, and the ER discharge summary directed that the sodium level be redrawn on 1/26/26. Review of the resident’s medical record showed no evidence that this lab draw occurred on the specified date. Instead, a nursing progress note dated 1/29/26 documented that the resident had a critical sodium level of 121, the on-call provider was notified, and the resident was transferred back to the ER. In an interview, the DON and Administrator reported that the DON spoke with the facility provider on 1/27/26 and that the sodium level was ordered to be drawn on 1/29/26, the facility’s regular lab day, but this conversation was not documented in the clinical record. The DON acknowledged that she could have drawn the lab herself when she became aware of the order but did not, and confirmed that the lab should have been drawn on 1/26/26 as directed by the ER provider. This sequence of events shows that the facility did not follow the ER provider’s order for a sodium redraw on the specified date, did not document the reported provider communication regarding rescheduling the lab, and did not take available steps to obtain the lab in a timely manner, resulting in the resident’s sodium level not being reassessed until it was critically low and necessitated another ER transfer.
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