A resident with multiple comorbidities, severe cognitive impairment, and an indwelling catheter had a urine culture that returned positive for MRSA following a physician-ordered UA. The abnormal result was obtained but not communicated to the physician for an extended period, and documentation showed the physician was not notified until much later, when an antibiotic was finally ordered for a UTI. The ADON confirmed the absence of timely notification in the record, despite a facility policy requiring nurses to review lab results and promptly notify the physician of significant abnormalities.
Failure to complete ordered lab tests for a resident with epilepsy, dysphagia, DM2, bipolar disorder, dementia, and gastrostomy status. The resident had significantly impaired cognition and depended on tube feeding for most nutrition and fluid needs. A physician ordered CBC with diff, BMP, and Hgb A1C every 6 months, but the chart showed the last labs were completed months earlier, and the Administrator confirmed no labs were done before the order was discontinued.
A resident with multiple fractures, thrombocytopenia, and hypertension had physician orders for a CBC and BMP that were not completed as ordered, as confirmed by medical record review and provider notes. A later set of CBC and BMP orders was carried out. The resident also had an order for a wound culture and sensitivity; the initial specimen was rejected by the lab due to use of an expired swab, and there was no documentation of an immediate recollection despite instructions to obtain a new specimen. The DON confirmed that the earlier labs were not completed and that the wound culture was collected with an expired swab and not recollected until a later date.
Ordered lab tests were not completed for a resident with acute kidney failure, severe protein calorie malnutrition, COPD, A fib, depression, anxiety, and weight loss. The resident’s orders included CBC, CMP, A1c, TSH, vitamin B12, and vitamin D, but the record showed no evidence the tests were done, and the DON confirmed the labs were not completed as ordered.
A resident with multiple complex conditions, including UTI, spinal cord issues, CKD, an unstageable pressure ulcer, and diabetes, had a physician order for weekly morning CBC, e-diff, platelets, BMP without glucose, and hepatic function panel during Meropenem therapy, with results to be sent to the physician. Record review showed that the ordered labs were not completed on two scheduled weeks, and the DON confirmed there was no evidence the labs were obtained as ordered.
The facility did not obtain or complete physician-ordered laboratory tests for three residents with complex medical needs, including those with diabetes and chronic illnesses. Despite orders for regular lab monitoring, required tests such as Hemoglobin A1C, TSH, Depakote levels, CBC, CMP, and uric acid were missed or not performed as scheduled. Staff interviews confirmed the absence of a tracking system for labs and no formal lab policy, resulting in missed tests for multiple residents.
A resident with multiple chronic conditions and urinary incontinence had a urinalysis and urine culture ordered by a nurse practitioner after reporting dysuria. Although the Medication Administration Record indicated the specimen was collected, interviews and record review confirmed the lab never received the sample, and the ordering provider was not notified of the missing results, contrary to facility policy.
A resident with multiple chronic conditions experienced a delay in UTI treatment due to the facility's failure to promptly obtain and report laboratory results to the provider. The order for a urinalysis and culture was not placed until two days after symptoms were noted, and the final lab results were not reported to the nurse practitioner for an additional three days, resulting in a delay in starting antibiotic therapy.
A resident with multiple medical conditions was prescribed IV Vancomycin with orders to obtain Vancomycin levels weekly. The facility began administering the antibiotic but did not obtain the required Vancomycin level until several days after starting treatment, despite pharmacy recommendations and standing orders. This delay in laboratory monitoring was confirmed by both the pharmacist and the administrator during the investigation.
A resident with multiple medical conditions and moderate cognitive impairment did not receive physician-ordered BMP and CBC lab tests as scheduled, with the last tests completed several months prior to the required date. Facility leadership confirmed the lapse and could not provide a policy on following physician orders.
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