F0684

D

Failure to Complete STAT Lab Orders and Required Monitoring

Richton Park, Illinois Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow a physician’s STAT (immediate) laboratory orders and associated monitoring orders for one resident. A registered nurse (V13) reported that she received STAT lab orders for the resident, called the lab, and obtained a confirmation number, then endorsed the pending lab work to the oncoming shift. However, there was no evidence that the STAT labs ordered on 12/31/25, specifically a complete blood count and comprehensive metabolic panel, were ever drawn. Additionally, there was no documentation on 1/1/26 of any follow-up related to the STAT labs or of any vital signs being obtained for the resident, despite existing physician orders for vital signs three times daily and blood sugar monitoring three times daily.

The Director of Nursing (V1) stated that her expectation is that nurses carry out all physician or nurse practitioner orders and follow up on STAT labs by calling them in, obtaining a confirmation number, and, if endorsed to the next shift, ensuring the next nurse checks the lab’s estimated time of arrival or notifies the provider if the lab cannot be drawn. The facility’s policy on following physician orders, revised 6/18/23, states that all physician orders received for a resident will be implemented and followed throughout the resident’s stay. The affected resident is an older adult with multiple significant diagnoses, including myopathy, spinal stenosis, hypertensive heart disease, heart failure, chronic kidney disease stage 3, unspecified atrial fibrillation, type 2 diabetes, morbid obesity, peripheral vascular disease, anemia, and a history of falls, and had admission orders including Midodrine, Ensure supplement, vital signs three times daily, blood sugar monitoring three times daily, and the STAT labs that were not completed.