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
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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.
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.
A resident on transmission-based precautions had a physician-ordered urinalysis culture and sensitivity collected by a contracted lab, but the test results were not filed in the clinical record as required by facility policy. During record review, surveyors found no lab report in the chart, and the ADON/IP later produced a copy of the results and acknowledged they had not yet been filed. These findings were discussed with facility leadership during the exit conference.
Missing Laboratory Results in Resident Records: Survey review found that lab reports were not filed in the charts for multiple residents. Missing documentation included urine culture results, CBC, BMP, VIT D, CMP, ESR, and CRP results, and one CBC was later found to have been cancelled because the sample was clotted. Staff, including the DON and Corporate QA Nurse, were unable to locate the results in the medical records and obtained some reports directly from the lab website or lab after the surveyor requested them.
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 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.
Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
Missing Laboratory Results in Resident Records
Penalty
Summary
Complete, dated laboratory records were not maintained in the residents' clinical records for 5 of 25 sampled residents. Survey review found missing urine culture and blood laboratory results for multiple residents, and one resident's clotted sample result was not located in the medical record. The missing records involved residents 3, 7, 8, 33, and 56, and the facility staff were unable to locate the expected laboratory documentation during the survey review. Resident 56 had diagnoses including fracture of the left femur, fracture of the right femur, repeated falls, and overactive bladder. After an infection prevention/control note documented a urine dip and physician notification for possible UTI, with an order for Septra and urine C&S, the urine culture results could not be found in the resident's medical record. The DON stated she was unable to locate the urine culture results and said Medical Records uploaded records to resident charts, with results expected within one business day. Resident 3 had diagnoses including hypo-osmolality and hyponatremia and chronic kidney disease with heart failure. A physician ordered UA with C&S for possible UTI, and the record later showed the lab reported mixed flora, probably contamination, with the C&S not completed; however, the laboratory results were not in the resident's record until the surveyor requested them. Resident 33 had diagnoses including myopathy, sepsis, pneumonitis due to inhalation of food and vomit, and Alzheimer's disease; a CBC and CMP were ordered, the CMP was present, but the CBC was missing from the record and later obtained from the lab as a cancelled clotted sample. Resident 7 had diagnoses including attention to colostomy, atrial fibrillation, schizophrenia, epilepsy, and neuromuscular dysfunction of bladder; CBC, BMP, and VIT D results collected for the ordered labs could not be located in the record. Resident 8 had diagnoses including cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia; CBC, CMP, ESR, and CRP results ordered for the resident could not be located in the medical record, and the DON stated the facility would call the lab if results were not received.
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