Failure to Document Lab Results in Resident's Record
Summary
The facility failed to ensure that physician-ordered laboratory test results for a resident, identified as R31, were included in the resident's clinical record. This oversight was discovered during a review of R31's Electronic Medical Record (EMR), which documented several diagnoses including hypertension, diabetes mellitus, urinary incontinence, and a neoplasm of the right breast. The resident's Annual Minimum Data Set (MDS) indicated moderately impaired cognition and a need for substantial assistance with toileting hygiene. Despite urine analyses being ordered on multiple occasions for possible urinary tract infections, the clinical record lacked evidence of the culture and sensitivity results for these tests. Upon investigation, it was found that the culture results were sent to the physician for review but were not scanned into the resident's medical record as required. An administrative nurse confirmed that the results had not been properly documented in the EMR. Additionally, the facility did not provide a policy related to laboratory tests, which contributed to the deficiency. This failure to include critical laboratory test results in the resident's clinical record could lead to unnecessary tests and delayed treatment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Monthly CBC Results in Resident Record: A resident with schizophrenia, CHF, and an intracranial injury had active physician orders for monthly CBCs related to clozaril use, but multiple monthly CBC results were not filed in the EMR. During interview, the RDCS stated lab results should be uploaded under the Documents or Results tab, and if they were not there, the facility likely did not have a record that the labs were completed.
Missing Urinalysis Result in Resident Record: A resident with severe cognitive impairment, an indwelling urinary catheter, and chronic UTIs had a urinalysis ordered for behavioral and cognitive changes. The specimen was collected, but the result was not found in the chart, and the DON confirmed there was no indication it had been tested at the lab or that the facility had attempted to obtain or follow up on the result.
A resident with paraplegia, osteomyelitis, anemia, PTSD, depression, anxiety disorder, and insomnia had a physician-ordered urinalysis, but the lab report was not found in the medical record. The DON later requested the results, and the RNC emailed the lab report, stating it had been sent to the provider but was not sure why it was not filed in the resident’s chart.
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.
Missing and Unreported Laboratory Results: The facility failed to keep complete lab records for one resident with vascular dementia, diabetes, and hyperlipidemia, whose ordered CBC, CMP, A1C, vitamin studies, lipid panel, and magnesium results were not found in the chart. The facility also failed to ensure lab results for another resident with CKD, anemia, and severe cognitive impairment were reported to the provider; although CBC, CMP, vitamin D, and magnesium labs were ordered and documented as drawn, the results were not initially located in the record and the DON stated the facility used multiple labs with only one linked to the portal.
Missing Lab Results in Resident Records: The facility did not keep complete lab records in the clinical charts for two residents. One resident with schizophrenia, OCD, dementia, and adult failure to thrive had ordered CBC, CMP, TSH, Depakote, ammonia, B12, and UA results that could not be located in the chart, while another resident with AFib, DM, anxiety, and bacteremia had ordered weekly CBC w/diff, CMP, CRP, and CK results missing from the record. RN and DON interviews confirmed the lab values were available on the portal or had been faxed, but were not filed in the residents' medical records.
Missing Monthly CBC Results in Resident Record
Penalty
Summary
Keep complete, dated laboratory records in the resident's record was not met for 1 of 19 sampled residents when the facility did not ensure that ordered CBC laboratory results were filed in the resident's clinical record. Resident 12 was admitted and later readmitted with diagnoses including schizophrenia, chronic diastolic congestive heart failure, and unspecified intracranial injury. The resident had physician orders for monthly CBCs related to clozaril use, first dated 9/29/25 and later continued on 3/6/26, but the medical record reviewed from 6/1/26 through 6/4/26 did not contain monthly CBC results for June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026. During interview, the Regional Director of Clinical Services stated that lab results should be uploaded under the Documents tab or Results tab in the electronic medical record, and if they were not found there, it was likely the facility did not have a record that the labs were completed.
Missing Urinalysis Result in Resident Record
Penalty
Summary
Laboratory reports were not kept in the resident's medical record for one resident with severe cognitive impairment and multiple diagnoses including bladder obstruction, renal insufficiency, heart failure, diabetes mellitus, non-Alzheimer's dementia, and a history of cerebrovascular accident. The resident had an indwelling urinary catheter and chronic UTIs, and a physician order dated 3/17/26 directed a urinalysis after behavioral and cognitive changes and due to the history of chronic UTIs. A urinalysis was collected on 3/19/26, but there was no evidence in the medical record that the facility received the result or followed up on it. The DON confirmed on 5/21/26 that the urinalysis result was not in the chart, there was no indication it had been tested at the laboratory, and the facility had not attempted to obtain or follow up on the result.
Missing Laboratory Report in Resident Record
Penalty
Summary
Complete, dated laboratory records were not kept in the resident's clinical record for 1 of 40 residents sampled. Resident 8 was admitted and later re-admitted with diagnoses including paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 3/21/26, the physician ordered a urinalysis, but no documentation of the laboratory results could be found in the resident's medical record. On 4/27/26 at approximately 8:00 AM, the DON was asked to provide the urinalysis results, and at 8:40 AM the RNC emailed the laboratory results. At 9:40 AM, the DON stated the urinalysis results had been obtained from the laboratory, and the RNC stated she had a copy from the laboratory at one point because it was sent to the provider, but she was not sure why it did not make it into the resident's medical record.
Missing Lab Results in Medical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were accurately maintained and readily available in the medical record for 2 of 32 sampled residents. For Resident 3, who was admitted and later readmitted with diagnoses including hypo-osmolality, hyponatremia, and anxiety, a physician order dated 12/28/25 required additional labs for 12/29/25, including ferritin level, serum iron, transferrin, and TIBC for anemia. Those laboratory tests dated 12/29/25 were not located in Resident 3's medical record during review from 3/16/26 through 3/19/26. For Resident 4, who was admitted with diagnoses including vascular dementia, depression, PTSD, constipation, and prediabetes, a physician order dated 1/26/26 revealed a TSH with reflux to free T4. The record showed the T4 was completed on 1/26/26, but there were no TSH results in the medical record. During interview on 3/19/26, the DON stated the TSH had been completed but was not in the record and needed to be manually printed from an external portal and scanned into the medical record; the DON stated the TSH results should have been in the medical record.
Missing and Unreported Laboratory Results
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident record for Resident #6 and failed to ensure provider-ordered laboratory results were filed in the clinical record. Resident #6 had diagnoses including vascular dementia, diabetes, and hyperlipidemia, and a quarterly MDS assessment showed a BIMS score of 5, indicating severe impairment in cognitive skills for daily decision making. Provider orders were entered for a CBC, CMP, hemoglobin A1C, vitamin B12, lipid panel, vitamin D, and magnesium, and the same laboratory tests were ordered again shortly afterward. During record review, the surveyor could not locate the results in the clinical record, and the Nurse Officer Assistant later provided copies of laboratory results obtained on 01/29/26 and 02/06/26. The Director of Education stated the laboratory results should have been included in the clinical record. The facility also failed to report laboratory results obtained for Resident #31 to the provider. Resident #31 had diagnoses including chronic kidney disease, vitamin D deficiency, deficiency of other B group vitamins, hypertension, and vascular dementia, and an MDS assessment showed a BIMS score of 01 out of 15, indicating severe cognitive impairment. An NP note documented chronic anemia managed with ferrous sulfate and folic acid, and ordered CBC, CMP, vitamin D, and magnesium labs. A nursing note documented that the labs were drawn, but later NP notes stated the blood was not drawn and would be followed up. The January physician order summary showed the labs were ordered for one time only, and the results were not initially located in the clinical record. The DON stated the facility used three different labs based on insurance, only one was connected to the medical record portal, and there was no single staff member responsible for ensuring labs were completed and results received timely.
Missing Lab Results in Resident Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the residents' clinical records for 2 of 24 sampled residents, identified as Residents 25 and 43. Resident 25 was admitted and later readmitted with diagnoses including schizophrenia, obsessive-compulsive disorder, dementia, and adult failure to thrive. A physician order dated 6/18/25 required CBC, CMP, Depakote, and TSH every 6 months, and another order dated 11/25/25 required CBC, CMP, TSH with reflex T4, ammonia, B12, and UA with micro and reflex to culture, with instructions to obtain a urine sample and draw labs the next day. The lab results for both orders could not be located in the resident's medical record. Resident 43 was admitted with diagnoses including atrial fibrillation, diabetes mellitus, generalized anxiety disorder, and bacteremia. A physician order dated 12/10/25 required CBC with differential, CMP, CRP, and CK every Wednesday. No results from 12/24/25 were found in the medical record. During interview, RN 1 printed the missing lab values from the online portal and stated they had not been signed by the physician and filed in the record. The DON stated lab results were faxed to the facility and also available on the online portal, and that after physician signature they were filed in the residents' medical records, but she was unable to find the 12/24/25 lab draw for Resident 43.
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