Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
The deficiency involves the facility’s failure to carry out ordered laboratory tests (CBC and CMP) in a timely manner for one resident. The resident had a diagnosis of metabolic encephalopathy and behavioral disturbances. On February 4, 2026, the NP documented the resident’s condition, and a physician order was written the same day for a CBC and CMP to be completed on February 5, 2026. The February 2026 Treatment Administration Record indicated that the CBC and CMP order was entered as being done on February 4, 2026, even though the order specified testing on February 5, 2026. A review of the resident’s laboratory results showed that the CBC and CMP ordered for February 5, 2026, were not actually performed until February 11, 2026. The February 11 blood work revealed abnormal values, including an elevated WBC of 16.8, creatinine of 2.86, and BUN of 79. A physician order dated February 11, 2026, included an order for 0.45% sodium chloride IV hydration. During an interview, the DON stated that the February 5 blood work order had not been entered into the laboratory system and therefore was not completed as ordered, and that this missed blood work was not identified until an audit on February 10, 2026. The DON confirmed that the laboratory order for February 5, 2026, was not followed in a timely manner.
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