| 3992 |
ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY |
115727 |
113 SPRING VALLEY ROAD |
JEFFERSONVILLE |
GA |
31044 |
2017-08-10 |
505 |
D |
1 |
0 |
5YLC11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of the facilities written policy titled Laboratory, Radiology and other Diagnostic Services it was determined that the facility failed to ensure laboratory orders were implemented and results were reported timely in accordance with the facilities written policy for one Resident (R#1) out of 3 residents. Finding include: Upon admission to the facility on [DATE] R#1's [DIAGNOSES REDACTED]. Review of the clinical record it was documented on a form titled Physician's Interim/Telephone orders dated 6/5/17 notes, Admission labs: Hemoglobin A1C (HgbA1C) (blood test to monitor the glucose control of a patient over the last three months) , Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Lipids. During an interview with the DON on 8/10/17 at 12:00 p.m., regarding the lab ordered dated 6/5/17 the DON replied, he went to the hospital on the 5th due to a fall. Upon further review of the record a form titled Clinical Laboratory Services, dated 6/5/17 at 10:27 a.m., and the same form dated 6/6/17 at 10:27 a.m., both days were noted No Requisition Received for Comprehensive Metabolic Panel , Lipid Panel, CBC with Diff, PSA screening, and HGB A1C. Futher record review revealed the next Clinical Laboratory Services form in the clinical record was dated 6/13/17 the results reported to the facilty was on 6/13/17 at 1:46 p.m. The report revealed outside range for ; Sodium 159 (136-145), Chloride 114 (98-107), Glucose 518 (70-105). Further record review revealed that at 3:30 p.m. on 6/13/17 LPN BB documented in the 'Skilled Daily Nurses Notes' crtical labs were reported to the doctor. During an interview with Director of Nursing (DON) on 8/10/17 at 12:00 p.m., regarding the time lapse between when the lab report was received for R#1on 6/13/17 and the time LPN BB documented the physician was notified of the out of range results, she replied the labs may have been here at the time on the lab report but maybe the nurse did not get a copy of the results until the time noted, which I do not think is a delay. During interview with the Medical Records/Central supply staff on 8/10/17 at 1:12 p.m., in the presence of the DON regarding the facilities system to manage laboratory orders including out of range results she stated, all labs are faxed to the facility and placed in my mail box up front or I can view the labs right here on my computer. She continued to say, I check my box at least one time each day around 6:30 a.m., and I can pull results from my computer. I always fax the labs that are within range to the MD and I give all out of range labs directory to the nurse to call the physician. When asked about the policy regarding the documentation on a form titled Patients Log Book she replied, the sheets for R#1 labs have been removed from the book and I cannot find them, sometimes they are put in the garbage. During further intervew regarding the form titled Clinical Laboratory Services, dated 6/5/17 at 10:27 a.m., and 6/6/17 at 10:27 a.m., that was noted No Requisition Received, she said a few months ago we opened the other unit and the people from the lab did not know we had residents over there, so the labs were missed. Review of the Laboratory Radiology and other Diagnostic Services policy notes, Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and require immediate attention at which time the Physician will be notified upon receipt. The laboratory policy notes the MD will be notified immediately with results that require immediate attention. And the results will be logged in the lab book upon receipt. |
2020-09-01 |