Failure to Ensure Accurate Entry of Resident Information for Lab Specimens
Summary
The facility failed to ensure accurate entry of resident information for laboratory specimens, resulting in the rejection and cancellation of samples for a resident. On September 3, 2024, a resident was ordered to have blood samples for a Comprehensive Metabolic Panel (CMP), Lipid Panel, Complete Blood Count (CBC) with differential, and a stool sample for Clostridioides difficile (C-diff). However, the outside laboratory company rejected these samples due to incorrect Date of Birth (DOB) information on the specimen tubes and cup, which was not corrected despite confirmation with the nurse. Further review revealed that on September 23, 2024, another blood sample for a CBC with differential was also rejected for the same reason. The Director of Nursing (DON) confirmed that the facility used an outside company for laboratory results and that nurses were responsible for entering orders into a web-based system, including the resident's DOB. The DON acknowledged that both samples, one obtained by the outside lab and the other by the facility's nurse, were discarded due to the same error, indicating a systemic issue in the process of labeling and entering resident information for laboratory specimens.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not maintain or provide a written agreement with a CLIA-certified laboratory to ensure timely access to required lab services when on-site services were not available. During surveyor review of facility documents and policies, no contract or agreement for laboratory services could be found. The Administrator reported being unable to locate the laboratory services contract, stating that important document binders had been moved during a recent facility-wide evacuation, and the facility was unable to produce any documentation showing how lab services were formally arranged.
A resident with an elevated potassium level had physician orders for repeat lab tests, but staff failed to obtain the required laboratory studies on the specified dates. The DON confirmed that the ordered lab work was not completed, and clinical records lacked evidence of the tests being performed.
A resident with multiple chronic conditions and severe cognitive impairment did not have physician-ordered laboratory tests completed prior to a scheduled specialist appointment. The omission was confirmed through medical record review, family interviews indicating missed or rescheduled appointments, and verification by the DON.
A resident with multiple medical conditions did not have laboratory tests completed as ordered by the physician, with only a few results present in the record and several missing. The DON and an RN confirmed that required lab results were not available in the medical record, and the physician had not been updated on some findings.
A resident with a Stage IV pressure ulcer and multiple diagnoses did not receive physician-ordered pre-albumin and CBC lab tests. The tests were ordered and sent to the lab, but were not completed, and no results or documentation were found in the medical record. The lab was unable to provide a reason for the missed testing.
A resident with multiple serious conditions experienced a decline, prompting a physician to order STAT CMP and CBCD labs. The facility did not obtain these STAT labs as ordered, with staff stating their contracted lab did not provide STAT services on the needed day, despite the contract allowing for such services. The resident's condition worsened, and the labs were not completed prior to the resident's transfer out.
Failure to Maintain Written Agreement for Laboratory Services
Penalty
Summary
The facility failed to maintain and provide a written agreement with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory to ensure timely availability of required laboratory services when such services are not provided on-site. During document and policy review, surveyors were unable to identify any written agreement or contract verifying arrangements for laboratory services. In an interview, the Administrator reported being unable to locate the requested laboratory services contract at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation. The facility ultimately could not produce documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Failure to Obtain Physician-Ordered Laboratory Studies
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one resident. Clinical record review showed that a resident had an elevated potassium level, and the physician ordered a repeat Basic Metabolic Panel (BMP) to be done on a specific date. However, documentation revealed that the repeat BMP was not completed as ordered, and a subsequent order for a Comprehensive Metabolic Panel (CMP) was also not carried out. An interview with the Director of Nursing confirmed that staff did not obtain the required lab work on the dates specified by the medical practitioner. There was no evidence in the clinical records that the laboratory tests ordered by the physician were completed as required.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with multiple chronic conditions, including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. The resident, who had severely impaired cognition, was admitted on 01/15/25 and had a follow-up nephrology appointment scheduled for 07/20/25, with laboratory tests ordered to be completed on 07/14/25. These tests included a complete blood count, hepatic function panel, magnesium, microalbumin/creatinine ratio, renal function panel, sodium, protein/creatinine ratio, and urinalysis. Review of the medical record showed no evidence that the laboratory tests were completed as ordered. Family interviews confirmed that the facility had not completed the ordered tests prior to appointments, resulting in rescheduled or missed appointments. The Director of Nursing verified that the laboratory tests were not completed as ordered.
Failure to Complete and Document Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing for a resident was completed as ordered by the physician. The resident, who had diagnoses including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis, had multiple active laboratory orders for monitoring various conditions and medications. These orders included regular Albumin levels, CBC, BMP, Depakote levels, and other specific tests at weekly, biweekly, monthly, and multi-month intervals. Review of the resident's medical record revealed that many of these laboratory tests were not completed as ordered, with only a few laboratory results present in the record for specific dates. Further review and interviews with the DON and an RN confirmed that several laboratory results were missing from the medical record, and the physician had not been updated on some of the laboratory findings. During the survey, the RN was observed printing some missing results from the laboratory services website, but the DON was unable to provide evidence of other required laboratory testing being completed. This failure to complete and document laboratory testing as ordered constituted the deficiency.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by the physician. A resident with a history of stroke and dementia had a Stage IV pressure ulcer on the coccyx, and a physician ordered pre-albumin and complete blood count (CBC) laboratory tests. Review of the medical record showed that the results of these tests were not present, and there was no documentation that the laboratory testing had been completed. During an interview, the wound nurse confirmed that the tests had been ordered and sent to the lab, but the lab did not complete the tests as scheduled and could not provide a reason for the failure.
Failure to Obtain STAT Laboratory Services as Ordered
Penalty
Summary
The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.
Plan Of Correction
Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
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