In a March 9, 2009 survey conducted at Rivington House – The Nicholas A. Rango Health Care Facility , a Manhattan (NYC) nursing facility, surveyors found that the NYC facility failed to develop and implement policy and procedures to track and monitor laboratory orders and results. The 52 year-old resident that was the subject of the investigation was admitted to the facility with a medical history of Coronary Artery Disease, status post a bypass graft, and Hypercholesteremia.
The resident had been prescribed Coumadin for DVT prophylaxis after the bypass graft surgery. However, PT/INR (Prothrombin Time/ International Normalized Ratio) tests were not performed for two consecutive weeks as ordered. Once recognized, the resident was admitted to the hospital with critical lab values, and then subsequently expired at the hospital due to a cerebral hemorrhage.
The surveyors found that the NYC facility had no system in place to ensure that all physician laboratory orders, specifically standing orders, are completed. They also found that Rivington House failed to implement a system to ensure that the labs were actually drawn and the results subsequently obtained. As a result of the surveyors’ findings and the facility’s neglect, Rivington House was fined $45,750 in federal sanctions.
