Missing Lab Results in Medical Records: The facility failed to keep lab reports accurately maintained and readily available in the medical record for two residents. One resident had ordered anemia-related labs, including ferritin, serum iron, transferrin, and TIBC, that were not found in the chart, and another resident had a TSH order with reflux to free T4 where the T4 was present but the TSH result was missing. The DON stated some results had to be manually printed from an external portal and scanned into the record, and that the missing TSH should have been in the chart.
Two residents with complex medical conditions had laboratory tests ordered, but the results were not filed in their clinical records. Staff interviews revealed that issues with the online lab portal and differences in handling STAT versus routine labs contributed to the missing documentation, as results were not consistently uploaded to the residents' medical records.
Two residents did not have all required laboratory results filed in their medical records, including a missing urine culture and a missing urine microalbumin result. The ADON confirmed that these results were not present in the records and had to be obtained from external sources.
A resident with multiple chronic conditions had a physician's order for a vaginal culture due to vaginal discharge, but the resulting laboratory report was not filed in the electronic medical record. Staff confirmed that the lab results from an outside facility were not requested or uploaded as required.
The facility did not ensure that laboratory results for several residents were filed in their medical records as required. For four residents with complex medical conditions and multiple lab orders, the actual lab reports were missing from their clinical files, despite documentation that labs were ordered and sometimes reviewed. This deficiency was confirmed through record review and staff interviews, revealing a breakdown in the process for uploading lab results.
A resident with multiple chronic conditions had physician orders for several CBC tests, but the corresponding laboratory results were not found in the clinical record. The facility used two EHR systems, and the lab uploaded results to both; however, Medical Records staff only had access to one system, leading to the omission of required lab reports in the resident's record.
A resident with multiple chronic conditions did not have required serum phenytoin and phenobarbital lab results documented in the electronic medical record, despite pharmacy recommendations and physician approval for these labs. Staff interviews revealed that while diagnostic results were supposed to be scanned and uploaded promptly, the necessary laboratory reports were missing from the resident's chart.
The facility did not consistently file laboratory reports in the clinical records for three residents, resulting in missing or misfiled lab results for routine and stat orders, including respiratory panels and metabolic panels. Staff interviews confirmed that some results were delayed, not uploaded, or placed in the wrong chart, leading to incomplete documentation.
The facility did not ensure that laboratory reports were filed in the medical records for four residents who underwent diagnostic testing and received treatment for infections and other conditions. Despite orders and administration of antibiotics and other interventions, the required lab documentation was missing from the residents' records, as confirmed by staff interviews and record review.
The facility failed to maintain complete and timely laboratory records for several residents, resulting in missing or delayed documentation of test results in their medical records. The DON and nursing staff acknowledged issues with receiving results from the lab and inconsistent follow-up, impacting the care and treatment of the residents.
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