Failure to Provide Timely INR Results for Resident on Warfarin
Summary
The facility failed to provide timely INR level results for a resident, identified as R52, who was on warfarin sodium, a blood-thinning medication. R52 had multiple diagnoses, including end-stage renal disease, heart failure, and vascular disease, and was on anticoagulant medication. The care plan for R52 included monitoring for symptoms such as dizziness and irregular heartbeat and required staff to administer medications and draw labs as ordered, reporting any abnormalities promptly. However, there was a delay in communicating the INR results to the medical provider, which was crucial for managing the resident's condition. On several occasions, the INR results for R52 were not communicated promptly to the medical provider. For instance, the INR result obtained on 7/29/24 was not faxed to the medical provider until 7/30/24, and the response was not documented in the electronic medical record (EMR) until later. The registered nurse (RN) responsible for R52's care admitted to forgetting to enter the response into the EMR and did not investigate the cause of the subtherapeutic INR result. This oversight potentially placed the resident at risk for a blood clot or stroke, as the INR was below the therapeutic range. Interviews with facility staff, including the trained medication aide, licensed practical nurse, registered nurse, assistant director of nursing, and director of nursing, revealed inconsistencies in the process of handling INR results. The facility's policy did not adequately address the timely reporting of INR results or provide clear guidelines for staff on how to proceed when a response from the medical provider was not received. The medical director expressed dissatisfaction with the current fax system and emphasized the need for guidelines to ensure timely communication of INR results, especially when they are out of range.
Penalty
Resources
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A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
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.
Two residents experienced changes in condition that led to physician orders for a respiratory panel and a BMP, but staff did not ensure the ordered blood tests were collected and did not document any follow-up or physician notification when the tests were not performed. One resident with COPD and other chronic conditions had a new cough and loss of appetite, prompting an order for a respiratory panel that was never carried out. Another resident with heart failure, hypothyroidism, and AFib had episodes of diarrhea, nausea, and vomiting, leading to an order for a BMP that was not collected, as shown by the missing phlebotomist signature on the lab log. The IPN, DON, and ADON confirmed there was no documentation of lab follow-up or physician notification, and the facility’s lab/diagnostic test policy lacked procedures for tracking collection or notifying the physician when tests were not completed.
A resident with multiple chronic conditions, including DM, CHF, HTN, and CKD, had admission labs ordered, and subsequent CBC results showed critically low Hgb and Hct values. Although facility policy required immediate practitioner notification and documentation of abnormal lab values, there was no record that the physician or family were notified, and later MD notes and dietician entries indicated no labs were available or reviewed. The Medical Director confirmed she had not been informed of the critical results and that the signature on the lab report was not hers, while leadership and nursing staff acknowledged that nurses were responsible for monitoring labs, receiving critical values from the lab, notifying the physician via the message system or phone, and documenting this communication, which did not occur in this case.
The facility failed to correctly enter and process STAT and routine lab orders in the EMR and lab portal, causing delays and omissions in critical diagnostics for multiple residents. In several cases, providers ordered STAT CBC, CMP, imaging, and viral panels for residents with acute changes such as severe SOB, hypoxia, high fever, chest pain, vomiting, and confusion, but nursing staff either did not create STAT tickets in the lab system, entered the labs as routine instead of STAT, or did not enter all ordered tests. As a result, some labs were never drawn on the day ordered, some were not treated as STAT by the lab, and one ordered ammonia level was not completed. Providers, including the PCP and ARNP, reported they were unaware that STAT labs had not been completed and stated they expected timely completion of orders and notification of results.
The facility failed to consistently notify practitioners and document abnormal lab results for multiple residents. One resident with hypothyroidism had a markedly elevated TSH level reported, but the record lacked documentation that the practitioner was notified when the result was received, despite a care plan requiring lab monitoring and MD notification. Another resident with hypothyroidism had abnormal urinalysis findings after a change in mental status, with only a brief note that results were sent to the ARNP and no clear evidence of timely notification. A third resident with gout had repeated abnormal hematologic and BUN values, with documentation that initial results were sent to the physician but no entry indicating that subsequent abnormal labs were communicated, and the designated area for new labs in the daily note was left blank. Staff interviews confirmed that facility expectations require prompt practitioner notification and documentation of abnormal labs, which did not occur in these cases.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner of abnormal laboratory results for a resident. The resident was admitted with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, and had severe cognitive impairment and dependence on staff for activities of daily living, as well as an indwelling catheter. A physician order for a urinalysis was dated 06/11/25, and a urine culture completed on 06/14/25 showed a positive result for Methicillin Resistant Staphylococcal Aureus (MRSA). Despite the abnormal culture result on 06/14/25, review of the medical record showed no documentation that the physician was notified of these results until 06/27/25, when an order was obtained for Macrobid 100 mg by mouth twice daily for seven days for a urinary tract infection. During an interview, the ADON confirmed that the medical record did not contain documentation supporting timely notification of the physician regarding the abnormal lab results. The facility’s policy on lab and diagnostic test results required nursing staff to review results upon receipt, determine the urgency of communication based on the seriousness of abnormalities and the resident’s condition, and notify the physician using various possible communication methods.
Failure to Collect Ordered Labs and Notify Physician When Tests Not Performed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered laboratory tests were collected in a timely manner and that physicians were notified when those tests were not performed for two residents. For one resident admitted with COPD, HTN, and hyperlipidemia, with moderate cognitive impairment but largely independent in ADLs, a respiratory infection screener documented a new or increased cough and loss of appetite. A change in condition evaluation on the same day showed a new physician order for a respiratory panel. However, the respiratory panel order dated that day was not carried out, and there was no follow-up to ensure the specimen was collected. For the second resident, admitted with hypertensive heart disease with heart failure, hypothyroidism, atrial fibrillation, and a history of COVID-19, and documented as having severe cognitive impairment and needing extensive assistance with ADLs, a change in condition note recorded two episodes of diarrhea, with the physician and responsible party notified. Later that day, another change in condition note documented nausea and two episodes of vomiting. A physician order was then written for a one-time morning BMP. Review of the laboratory log showed no phlebotomist signature for this BMP order, indicating the specimen was not collected as ordered. Record reviews and interviews with the Infection Prevention Nurse showed that for both residents there was no documentation in change in condition follow-up notes or progress notes that the ordered labs were followed up for collection or that the physician was notified when the respiratory panel and BMP were not obtained. The IPN, DON, and ADON each stated the importance of collecting these labs and notifying the physician when they were not collected, but the facility’s written policy on lab and diagnostic test results did not include procedures for following up on whether tests were collected or sent to the lab, nor did it specify procedures for notifying the physician when a lab or diagnostic test was not collected or performed.
Failure to Notify Physician of Critical Lab Results and Document Communication
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of critical laboratory results and to document such notification, as required by facility policy. The facility’s Significant Condition Change and Notification policy required licensed nurses to immediately contact the medical practitioner for emergencies, including abnormal lab values, and to document each attempt to notify the practitioner and the resident’s representative. The Charting and Documentation policy further required staff to document the date and time specimens were obtained and the date and time the physician was notified of lab results. Despite these policies, the medical record for one resident contained no documentation that the physician or family were notified of critical lab findings. The resident was admitted with multiple significant diagnoses, including type 2 diabetes mellitus, heart failure, essential HTN, hypokalemia, hyperlipidemia, and chronic kidney disease stage 3. Admission orders included a CBC, CMP, TSH, BNP, and valproic acid level. A lab report collected several days after admission showed critically low hemoglobin of 5.1 g/dL and hematocrit of 18.7%, both flagged in the critical range. The lab report bore an illegible signature on the final page without a date, and there was no documentation in the resident’s chart that the physician or family had been notified of these critical results, nor any indication in subsequent physician notes that the labs had been reviewed. Over the following months, multiple progress notes by the dietician documented that no labs were located in the electronic medical record, and physician notes on several visits showed no documentation of lab review. Eventually, nursing notes documented that the resident was acting outside baseline with low blood pressure, and the family requested transfer to the hospital, where emergency department labs again showed severely abnormal hemoglobin and hematocrit values. Interviews with RN staff, the Medical Director, the DON, and the Administrator confirmed that nurses were responsible for monitoring lab results, that the lab should call the facility with critical values, and that staff were expected to notify the physician and document this notification. The Medical Director stated she had not been informed of the critical results, the signature on the lab report was not hers, and there was no record of staff notification, confirming that the facility failed to follow its own policies for critical lab result communication and documentation.
Failure to Properly Enter and Process STAT Lab Orders Resulting in Delayed or Missed Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to properly enter and process STAT and routine laboratory orders in the electronic medical record and the external lab portal, resulting in ordered labs not being drawn or not being treated as STAT for multiple residents. For one resident with dementia and hypertension, an ARNP ordered STAT CBC, CMP, chest x‑ray, and other diagnostics after the resident was noted with shortness of breath, labored breathing, and an oxygen saturation of 73% on room air. The LPN caring for the resident stated that the unit manager entered the labs into the lab website, but the lab company reported there was no phone call or requisition ticket for STAT labs and confirmed that no labs were drawn that day. Later that night, another LPN found the resident pale, gasping, with very low respirations and oxygen saturation despite oxygen, and a code blue was initiated with CPR and EMS transfer to the hospital. The PCP and ARNP both stated they were not aware the STAT labs had not been completed and expected the orders to be carried out and results communicated. Another resident with aphasia, hemiplegia, dementia, and a determination of incapacity had orders for CBC and CMP and, per staff and PCP interviews, was to have STAT labs, STAT chest x‑ray, flu and COVID swabs, nebulizer treatments, oxygen, and Ceftriaxone after presenting with fever over 102°F, oxygen saturation of 89%, labored breathing, and crackles in the lungs. The LPN who contacted the PCP reported that all labs and the chest x‑ray were ordered STAT, but the weekend supervisor entered the CBC and CMP as routine labs scheduled for a later date, and flu/COVID tests were not ordered until two days later. The medical record lacked documentation of the change in condition and the STAT nature of the orders on the day they were given. The resident’s labs were ultimately collected later, showing critically high sodium and other abnormal values, and the resident was later sent to the hospital with altered mental status, hypoxia, high fever, and was diagnosed with influenza A, septic shock, and multiorgan failure. A third resident, cognitively intact with diabetes, obesity, hypotension, and a gastrostomy, experienced vomiting, poor intake, and increased confusion. The provider ordered STAT CBC, CMP, and ammonia level for nausea, vomiting, and confusion. One LPN entered the STAT lab orders into the facility charting system while another LPN believed the first nurse would enter the orders into the lab system. The lab later reported that the orders were entered as routine, not STAT, and that while CBC and CMP were drawn and resulted, the ammonia level was not completed due to a specimen issue and was only noted in the portal. A fourth resident with atherosclerotic heart disease, Lewy body neurocognitive disorder, hypertension, and cardiomegaly had an episode of vomiting and chest pain with elevated blood pressure; the NP ordered IM medications, nitroglycerin, and STAT chest x‑ray, CBC, and CMP. The chest x‑ray was completed the same evening, but the CBC and CMP were entered as routine and not drawn until the next morning, with the lab confirming they were not processed as STAT. The DON and PCP acknowledged that the timing between ordering and completion was not acceptable for STAT labs and that there were problems with the lab process and nursing follow‑through on STAT orders.
Removal Plan
- The Director of Nursing was educated by the Regional Nurse Consultant on the process to review clinical records to validate diagnostic testing was completed per provider orders and that providers were notified of results.
- The Director of Nursing reviewed clinical records of current residents with diagnostic test orders from the prior 30 days to validate labs/diagnostic tests were completed as ordered and notified providers of any discrepancies.
- The Assistant Director of Nursing/Staff Development Coordinator began educating licensed nurses on the process to obtain STAT labs from the current lab service.
- The ADON/SDC educated licensed nurses on the process to obtain STAT labs from the current lab service.
- The Staff Development Coordinator began competency validation for licensed nurses on the process for obtaining routine and STAT labs.
- Step-by-step instructions for obtaining labs through the lab website (including STATs) were placed in the front of each lab binder.
- Licensed nurse education on the lab process, provider notification, and documentation was completed for nurses (with sign-in sheets and voice/text education reports used to validate completion).
- An ad hoc QAPI was completed with the Medical Director, Administrator, Director of Nursing, and additional IDT members addressing adherence to policy/process for change in condition, following provider orders, obtaining STAT labs, reviewing diagnostic results, and notifying providers; discussion included provider access to the EMR and ability to view lab/diagnostic results.
Failure to Notify Practitioners and Document Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify practitioners of abnormal laboratory results and to document such notifications as required by facility policy and resident care plans. For one resident with a primary diagnosis of a left ilium fracture and a care plan for hypothyroidism, a TSH level of 26.99 (reference range 0.45–5.33 uIU/mL) was reported by the lab on 3/7/26 at 5:55 p.m. The record later showed an order on 3/9/26 to increase Levothyroxine to 200 mcg daily and to repeat the lab in a week, and a nursing note that the resident’s son was informed of the medication increase and repeat lab. However, the documentation did not show that the practitioner was notified of the abnormal TSH result at the time it was reported, despite the care plan intervention to obtain and monitor labs and report results to the MD. Another resident with hypothyroidism had increased confusion documented, and the ARNP was notified with a request for labs. A urinalysis with microscopic exam was ordered and later reported with abnormal findings for urine blood, protein, mucus, and calcium oxalate crystals; the only documentation was that urine results were sent to the ARNP, without clear evidence of timely practitioner notification consistent with facility expectations. A third resident with idiopathic gout had multiple abnormal lab values (low RBC, Hgb, HCT; elevated Hemoglobin A1c and BUN) reported on 3/5/26, with a nursing note the next day stating results were sent to the physician. Subsequent labs on 3/7/26 again showed abnormal BUN and hematologic values, but the daily Medicare Managed Care note section for new labs was left blank, and there was no documentation that the physician was notified of these later abnormal results. Interviews with the DON, RN Unit Manager, and an LPN confirmed that staff are expected to notify practitioners of abnormal results as soon as possible and document this in the medical record, which was not consistently done for these residents.
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