Failure to Provide Ordered Weekly CBC Labs for Leukemia Monitoring
Penalty
Summary
The facility failed to provide ordered weekly laboratory services for a resident with myeloblastic leukemia. The resident was admitted with a diagnosis of myeloblastic leukemia, a condition associated with low hemoglobin and red blood cell counts, and was cognitively intact with a BIMS score of 13. On a documented date, the resident’s daughter and power of attorney informed the facility that the resident should be receiving weekly CBC tests, and the provider ordered weekly CBC labs accordingly. A subsequent health status note indicated that the resident would begin going to a local hospital for her weekly CBC draws due to past issues with the current lab services. The resident later stated that her daughter managed her labs but believed some had been missed, and the daughter reported that the lab technician was either not showing up or missing the resident, and that the facility had indicated it was not a big deal that the labs were not drawn. Laboratory records showed that the resident’s CBCs were drawn on three dates only, with no lab drawn on or shortly after the date the weekly order was initiated, and after a draw on a later date, there was nearly a three-week gap before the next lab was obtained. The DON stated that the initial failure to complete weekly labs after one of the draws was due to a nurse’s error when entering the order, and that after this error was corrected, the lab technician still failed to draw the resident’s labs on several occasions, specifically missing scheduled draws on two identified dates. The DON confirmed that these labs were intended to monitor the resident’s leukemia. The Administrator stated that the facility did not have a laboratory policy.
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