Failure to Obtain Lab Tests Leads to Resident's Psychotic Episode and Injury
Summary
The facility failed to obtain and provide necessary laboratory tests for a resident on Clozapine, an antipsychotic medication, which led to a significant health event. The resident, diagnosed with paranoid schizophrenia, had a physician's order for regular blood tests to monitor potential side effects of Clozapine. However, the required laboratory tests were not conducted as ordered on the specified date, and the results were not sent to the pharmacy, which was necessary for the medication's renewal. The oversight occurred when a nurse failed to place the necessary paperwork in the laboratory book, resulting in the phlebotomist not having the information needed to draw the resident's blood. Consequently, the pharmacy did not receive the required lab results, leading to the medication being put on hold. The resident missed several doses of Clozapine, which is known to cause rebound psychosis if abruptly stopped. This resulted in the resident experiencing an acute psychotic event, during which he fell and sustained serious injuries, including a broken shoulder and hip. Interviews with staff, including the nurse practitioner and pharmacist, revealed that the facility was aware of the requirement for lab tests before dispensing Clozapine. Despite this, the necessary steps were not taken to ensure the tests were completed and communicated to the pharmacy. The failure to follow through with the lab orders and communicate results led to the resident's medication being withheld, contributing to the resident's psychotic episode and subsequent injuries.
Removal Plan
- Resident #11's medication could not be administered as ordered by the provider due to it not being available. The nurse notified the pharmacy of the medication not being available to administer. The pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. The provider was notified, and an order was obtained to draw stat lab work. The results of the labs were received and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. The nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy, the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy. The pharmacy dispensed the medication. The facility received Resident #11's medication. Resident #11's medication of Clozapine was administered to the resident as ordered by the provider.
- An audit of all current residents was completed by the Director of Nursing to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of not obtaining lab services as ordered by the provider.
- Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- Education was provided by the Director of Nursing to licensed staff and licensed agency staff that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- The Quality Assurance team met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; when the order appears on the medication administration record the licensed nurse ensured the lab results were faxed to the pharmacy, and the results were received and faxed to pharmacy when applicable. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent an omission of ordered lab services with ordered lab work through the weekend reviewed for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for review and, if warranted, further action.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, dementia, and chronic lymphocytic leukemia returned from the ED with an order to recheck a WBC the next day, but nursing staff failed to arrange the lab draw. The AVS was reviewed later, the missed order was discovered, and staff stated the charge nurse was responsible for checking post-visit orders and that the lab order had been overlooked.
Missed Ordered Laboratory Testing: The facility failed to obtain multiple ordered labs for several residents, including PT/INR monitoring for a resident transitioning from Eliquis to Coumadin with a Lovenox bridge, urinalyses for residents with suspected UTI/CAUTI, CBC/CMP testing, anticonvulsant levels, blood cultures, and an ammonia level. One resident developed active bleeding with critically abnormal lab values and died in the facility while bleeding from multiple sites. The record also showed several ordered tests were not found or were not completed as ordered.
A resident with an abdominal surgical incision and left flank wound had a wound culture ordered after green drainage was noted from the wound vac, along with IV vancomycin and aztreonam. The culture was cancelled because the wrong tube was used, the wound was not re-cultured, and the wound nurse stated she had swabbed the fluid instead of the surgical site and believed the culture had already been completed.
A facility failed to obtain ordered lab services for a resident with HTN, anxiety, and muscle weakness. The record showed a provider ordered a CBC and BMP for monitoring, but documentation did not show the CBC was completed as ordered, and an IP confirmed the failure.
Ordered lab services were not completed for a resident with epilepsy. The resident had physician orders for a phenobarbital level and a TSH level, but neither test was drawn or resulted as ordered. An MDS nurse confirmed the missed labs, and the facility policy required timely lab services when ordered by the MD/NP/PA.
A resident's ordered BMP was not collected as directed because the order was not entered into the facility's online system with the correct collection date. An LPN stated the receiving nurse enters lab orders and the evening nurse collects the sample, and the DON confirmed the lab sample was not collected as ordered.
Failure to Arrange Ordered WBC Lab Draw After ED Return
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one resident when staff did not arrange a WBC lab draw after the resident returned from the ED. The resident had severe cognitive impairment and required maximal assistance with ADLs. Diagnoses included Alzheimer's disease, a history of TIA and stroke, heart disease, dementia, and chronic lymphocytic leukemia. The resident's care plan identified an alteration in health care status related to dementia, unstable gait, hypertension, chronic lymphocytic leukemia, osteoarthritis, and history of TIA, with goals including vital signs in acceptable range, pain controlled to mild range, and ordered labs in acceptable range. The ED provider notes stated the resident was to return to the facility and have the WBC rechecked the next day. The resident's progress notes showed the AVS from the ED visit was reviewed several days later, and the instructions to check a WBC were noted at that time. When the laboratory department was contacted, it reported that no lab draw had been performed on the ordered date. Interviews with nursing staff indicated the charge nurse on the resident's unit was responsible for checking orders after return from an appointment, hospital, or ED, and another nurse was to recheck completed orders. Staff stated the nurse who reviewed the AVS missed the lab order and did not call it into the lab.
Missed Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain multiple laboratory tests as ordered by medical providers for 8 of 51 sampled residents, including PT/INR testing, urinalyses, CBC/CMP testing, anticonvulsant drug levels, blood cultures, and an ammonia level. The report states that these missed labs involved residents with significant medical histories such as atrial fibrillation, recurrent urinary tract infections, chronic kidney disease, epilepsy, cirrhosis, and cognitive impairment. Facility policy required the facility to provide or obtain laboratory services to meet resident needs. For one resident, the deficiency involved repeated failure to obtain PT/INR testing during a transition from Eliquis to Coumadin with a Lovenox bridge. PT/INR labs were ordered every 48 hours, but several were not obtained. Later testing showed a PT greater than 90 and an INR that could not be calculated because the result was greater than linearity. The resident then developed active bleeding, including bleeding from the nose, mouth, urinary tract, and rectum. Additional labs showed critically low hemoglobin and hematocrit, and PT/INR could not be determined because there was no clot endpoint. The resident died in the facility while actively bleeding. The report also describes missed ordered labs for other residents. One resident with altered mental status and a history of recurrent UTIs had urinalysis orders that were not found in the record, while another resident with suspected CAUTI had a urinalysis with culture and sensitivity ordered but no result located. A resident on warfarin had PT/INR orders that were not obtained as scheduled, and another resident had ordered CBC and CMP testing that was not found. Additional residents had missing anticonvulsant levels, missing infection workup labs including CBC, BMP, magnesium, blood culture, and missing ammonia testing. Surveyors discussed these missing tests with facility leadership, and the record reflects that the ordered laboratory services were not completed or could not be located in the clinical record.
Wound Culture Not Completed as Ordered
Penalty
Summary
Timely, quality laboratory services were not provided for a resident with an abdominal surgical incision and left flank wound when a wound culture ordered for the resident was not completed as directed. The resident had diagnoses including COPD, hypertension, chronic kidney disease, and tremors, and the baseline care plan indicated moderate impairment in daily decision making and a need for partial to moderate assistance with toileting. The care plan directed treatment per physician orders for the surgical incision and wound care. A physician order indicated that a culture and sensitivity of wounds could be obtained if indicated, and a skin/wound note documented green drainage from the wound vac on the resident’s left rib. The physician assessed the wound and ordered a wound culture along with IV vancomycin and aztreonam, but the culture collected was cancelled because a red cap viral tube was used instead of the appropriate pink cap culture swab. The wound was not re-cultured, and the wound nurse stated she had swabbed the fluid rather than the surgical site and believed the culture had been completed, while also noting the resident could not start the antibiotics without the culture being completed.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one of five residents reviewed, Closed Resident Record CR99. The clinical record showed CR99 was admitted to the facility and had diagnoses of high blood pressure, anxiety, and muscle weakness. A physician order dated 6/17/26 directed the facility to obtain a CBC and BMP one time only for monitoring on 6/22/26. Review of the record did not reveal documentation that the CBC was obtained and completed as ordered on 6/22/26. During an interview on 7/23/26 at 1:11 p.m., Infection Preventionist Employee E7 confirmed that the facility failed to obtain laboratory services as ordered for CR99.
Ordered Laboratory Tests Not Completed
Penalty
Summary
Laboratory services were not completed as ordered for one resident with epilepsy. The resident was admitted on 04/03/25 and, according to the MDS dated 06/12/26, was cognitively intact and dependent on staff assistance for ADLs. Physician orders dated 06/05/26 included a phenobarbital level every six months and a TSH level every 12 months starting on 07/01/26. The medical record showed that neither the phenobarbital nor the TSH lab was drawn or resulted in July 2026. During interview on 07/23/26, the Regional MDS Nurse confirmed the ordered TSH and phenobarbital labs were not completed. The facility policy stated laboratory services must be provided or obtained when ordered by a physician and that the facility was responsible for the timeliness of those services.
Missed Ordered Lab Collection
Penalty
Summary
The facility failed to collect laboratory exams ordered by the physician for Resident #15. A physician order dated 06/17/26 directed a BMP in 10 days, but the record did not document lab results for 06/27/26, and the Treatment Administration Record for June 2026 showed the lab was not drawn as ordered. During interview, an LPN stated that when labs are ordered, the receiving nurse is supposed to enter the order into the facility's online system and set the appropriate completion date, and that the evening nurse would be responsible for collecting the resident's lab sample. The DON later stated that the physician's order for a BMP in 10 days was not entered into the system with the correct collection date, and the lab sample was not collected as ordered.
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