Failure to Collect Ordered Labs and Notify Physician When Tests Not Performed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were collected in a timely manner and that physicians were notified when those tests were not performed for two residents. For one resident admitted with COPD, HTN, and hyperlipidemia, with moderate cognitive impairment but largely independent in ADLs, a respiratory infection screener documented a new or increased cough and loss of appetite. A change in condition evaluation on the same day showed a new physician order for a respiratory panel. However, the respiratory panel order dated that day was not carried out, and there was no follow-up to ensure the specimen was collected. For the second resident, admitted with hypertensive heart disease with heart failure, hypothyroidism, atrial fibrillation, and a history of COVID-19, and documented as having severe cognitive impairment and needing extensive assistance with ADLs, a change in condition note recorded two episodes of diarrhea, with the physician and responsible party notified. Later that day, another change in condition note documented nausea and two episodes of vomiting. A physician order was then written for a one-time morning BMP. Review of the laboratory log showed no phlebotomist signature for this BMP order, indicating the specimen was not collected as ordered. Record reviews and interviews with the Infection Prevention Nurse showed that for both residents there was no documentation in change in condition follow-up notes or progress notes that the ordered labs were followed up for collection or that the physician was notified when the respiratory panel and BMP were not obtained. The IPN, DON, and ADON each stated the importance of collecting these labs and notifying the physician when they were not collected, but the facility’s written policy on lab and diagnostic test results did not include procedures for following up on whether tests were collected or sent to the lab, nor did it specify procedures for notifying the physician when a lab or diagnostic test was not collected or performed.
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