HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure a P&P was developed to guide the staff on processing STAT laboratory testing orders under an arrangement with an outside facility (Hospital A's laboratory services). This created the risk of delayed treatments for the patients.

Findings:

Review of the hospital's P&P titled Turnaround Times for Laboratory Results dated 3/23/21, showed the following:

* Test Orders With Routine or Timed Priorities: TAT is usually eight hours for routine orders. Timed test results are available within one hour of collection when testing is performed at the hospital. STAT orders are resulted within one hour of collection.

* CORE Lab General Testing Reports are usually available within 24 hours of receipt. Reference Lab TAT is usually less than seven days for orders with priorities of Routine or Timed.

On 3/26/25 at 0925 hours, the laboratory department was toured with the Regional Director of Laboratory Services and Phlebotomist 1. A specimen bin labeled "Hospital A" was observed in the refrigerator. Phlebotomist 1 stated the specimen would be sent to Hospital A for processing.

On 3/26/25 at 1211 hours, an interview and concurrent review of Patient 5's medical record was conducted with the CNO and Regional Director of Laboratory Services.

Review of the physician's order dated 3/25/25 at 1045 hours, showed to perform Retic and LDH blood testing STAT.

Review of the Orders and Results showed the following:

a. The blood sample for Retic testing was collected on 3/25/25 at 1200 hours. Hospital A's laboratory received the blood sample on 3/25/25 at 1628 hours (4 hours and 28 minutes after the collection). The test result was available on 3/25/25 at 1633 hours.

b. The blood sample for LDH was collected on 3/25/25 at 1055 hours. Hospital A's laboratory received the blood sample on 3/25/25 at 1628 hours (5 hours and 33 minutes after the collection). The test result was available on 3/25/25 at 1640 hours.

On 3/26/25 at 1211 hours, an interview was conducted with the Regional Director of Laboratory Services. The Regional Director of Laboratory Services stated the CORE Lab referenced in the P&P referred to Hospital A's laboratory.

The Regional Director of Laboratory Services also stated the Retic and LDH testing would be sent out to Hospital A's laboratory. The Regional Director of Laboratory Services stated the contracted delivery service transported specimens four times a day, but there was no specific delivery time, as the company makes rounds to multiple hospitals. The Regional Director of Laboratory Services and CNO acknowledged that there was no written P&P to guide staff on processing STAT testing that was sent to an outside facility.

On 3/27/25 at 0913 hours, the CNO verified these findings.