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:
Delayed urine specimen processing and lab submission: A resident with diabetes, urinary retention, and incontinence had a urine culture and urinalysis ordered after abnormal UA findings. The resident refused collection multiple times, then an RN collected the specimen and refrigerated it, but there was no documentation that the lab was contacted for pickup for several days. The specimen later resulted as contaminated, and a later urine sample was also contaminated and could not be processed.
Failure to obtain an ordered BMP for a resident with recent hyponatremia and multiple neurologic and fracture diagnoses. The resident returned from the hospital with discharge instructions for a BMP, but the lab result was not in the chart. The DON said the resident refused blood draws and the MD was aware, but there was no documentation of refusal or MD notification; the resident denied refusing labs, an RN confirmed no refusal, and the MD stated being unaware the BMP order had not been completed.
A resident with ESRD, CHF, cirrhosis, and A-fib had a physician order for daily PT/INR testing for two weeks due to increased results, but the MAR/TAR showed missed lab draws and the order was later discontinued. Nursing notes stated the lab could not come to the facility that weekend, and the DON, Facility Administrator, and RN reported the contracted lab service was only available once weekly and the hospital lab could not come to the facility.
Delayed urine specimen processing affected two residents with suspected UTI. One resident’s UA specimen could not be processed because the sample was not identifiable, and the replacement specimen and results were delayed. Another resident’s urine sample sat in the lab pickup box until several days later, and the culture was not performed because the specimen exceeded stability requirements.
A resident’s ordered hemoglobin A1c testing was missed twice in a row, with no documentation that the January and April labs were obtained. An LPN acknowledged the order was not followed, and the DON stated the A1c should have been collected as soon as the missing tests were identified.
A resident with critical hypokalemia did not receive a timely potassium re-check after an NP ordered the lab to be drawn by 3:00 PM. The TAR showed the order was not completed, and staff interviews confirmed the RN transcribed the order, the LPN did not obtain the draw that day, and the lab was not completed until the next day.
Delayed Urine Specimen Processing and Lab Submission
Penalty
Summary
The facility failed to ensure a urine specimen was collected, processed, and submitted to the laboratory in a timely manner for one resident reviewed for urinary tract infections. The resident had diagnoses including type 2 diabetes mellitus, thrombocytopenia, urinary retention, transient ischemic attack, and anxiety, and was cognitively intact, dependent on toileting hygiene, and always incontinent of urine. A physician ordered a urine culture and urinalysis, and when the laboratory could not perform sensitivity testing on the initial specimen because of abnormal leukocytes, the nurse practitioner ordered recollection. The resident refused urine collection multiple times on 05/21/26 and 05/22/26, though urine was eventually collected by an RN on 05/22/26 and placed in the refrigerator. The RN stated the laboratory needed to be contacted for pickup, but the record contained no documentation that the lab was contacted for specimen pickup from 05/22/26 through 05/26/26. The urinalysis report later showed three or more isolates, suggesting contamination. A subsequent urine specimen collected on 05/27/26 was also contaminated and results could not be obtained, and the nurse practitioner discontinued the urinalysis order.
Failure to Obtain Ordered BMP
Penalty
Summary
The facility failed to follow a physician order to obtain a BMP for one resident who had been hospitalized for hyponatremia and returned to the facility with discharge instructions that included a BMP to be collected on April 10, 2026. The resident’s record did not contain BMP results. The resident’s medical history included maxillary fracture, left lateral orbital fracture, hyponatremia, left-sided hemiplegia/hemiparalysis, Alzheimer’s disease, insomnia, subdural hemorrhage, metabolic encephalopathy, and depression. During interviews, the lab technician stated the resident’s last BMP had been collected in April 2025. The DON stated the lab draw process was to enter the order into the chart, send it to the lab company, and have the lab technician collect the specimen as scheduled, with results communicated to the physician. The DON later stated the resident did not have the BMP drawn because the resident refused blood draws and that the physician was aware, but there was no documentation in the resident’s record of refusal or physician notification. The resident stated the resident never refuses blood draws, and a registered nurse confirmed the resident did not refuse the blood draw on May 27, 2026. The physician later stated being unaware of the BMP order at discharge and unaware that it had not been processed or completed.
Missed PT/INR Lab Testing
Penalty
Summary
The facility failed to ensure laboratory services were provided for 1 of 3 residents reviewed for quality of care. Resident B had diagnoses including end stage renal disease, chronic heart failure, cirrhosis of the liver, and atrial fibrillation, and the most recent quarterly MDS dated 5/11/26 indicated the resident was cognitively intact and received dialysis services. Physician orders included PT/INR testing daily for two weeks due to increased results, starting 5/13/26, but the May 2026 MAR/TAR showed the lab test was not completed on 5/15/26, 5/16/26, and 5/17/26 before the order was discontinued on 5/18/26. Nurse's notes documented that the lab could not come to the facility that weekend to draw the resident's PT/INR and that the physician was aware. During interview, the DON and Facility Administrator stated the contracted lab service was unrealizable and would only come to the facility once a week, and that the facility attempted to use a local hospital lab service but hospital lab staff was unable to come to the facility. RN 4 stated the facility did not have a contract with the hospital lab. The facility later provided an outsourced lab contract that included PT/INR as STAT testing, but the ordered daily lab draws were not completed as documented.
Delayed Urine Specimen Processing and Lab Follow-Up
Penalty
Summary
The facility failed to provide timely lab services for two residents who had urine specimens collected for suspected urinary tract infection. One resident, admitted with acute pyelonephritis and cognitively intact, reported burning with urination and had a UA ordered; the specimen was sent to the lab the same day, but the facility later learned the specimen could not be processed because the resident’s name was not identifiable on the sample. A new UA order was obtained several days later, a new urine specimen was collected and sent, and the lab results were not returned to the facility until several days after that. The resident later returned to the hospital after a fall and was diagnosed with a UTI while hospitalized. A second resident, admitted with a shoulder fracture, had a provider visit note documenting suspected UTI with urine retention and an order to send a urine sample for evaluation. The urine sample was collected and placed in the laboratory box for courier pickup, but the specimen was not received by the lab until several days later. The final diagnostic report showed many bacteria in the urine and a culture was to be completed, but the culture was not performed because the specimen quality was inadequate and the urine sample exceeded the stability required for the test.
Failure to Obtain Ordered Hemoglobin A1c Testing
Penalty
Summary
The facility failed to obtain hemoglobin A1c laboratory testing as ordered for one resident who had an order dated 01/02/17 for hemoglobin A1c testing due in January, April, July, and October. Review of the resident’s laboratory results for January and April 2026 showed no documentation that the tests were obtained. A physician’s progress note dated 05/18/26 stated that an A1C was needed with the patient’s labs every 90 days and that it had been missed twice in a row. During interviews on 05/21/26, an LPN stated that lab requisitions were normally completed and labs collected on Tuesdays and Thursdays, acknowledged that the hemoglobin A1c test was not collected in January and April 2026, and stated that the physician’s order was not followed. The LPN later stated the hemoglobin A1c test was collected at 8:00 a.m. that day, and the DON stated the test should have been collected as soon as possible when the physician noticed the tests were missing.
Delayed Potassium Lab Draw
Penalty
Summary
The facility did not provide timely laboratory services for one sampled resident when a potassium re-check ordered for critical hypokalemia was not completed by the ordered time. The resident had diagnoses including paraplegia, pneumonia, diabetes, cirrhosis of the liver, and anxiety, and had intact cognition with a BIMS score of 15 out of 15. A lab result showed the resident’s potassium level was 2.7 mmol/L, and Nurse Practitioner E ordered oral potassium and a repeat potassium draw by 3:00 PM the same day. The resident’s TAR reflected the order for the potassium re-check, but it was not initialed as completed. During interviews, NP-E stated the re-check was not completed and said it was unacceptable, noting the order was given because of a critically low potassium level. RN-C stated the verbal order was received, oral potassium was given, and the lab order was transcribed, but the lab was not drawn as ordered. LPN-D stated the order did not specify a time and that by the time medication pass was completed it was after 6:00 PM, so the lab was not drawn. DON-B verified the potassium lab was drawn the next day instead of as ordered and was unsure why it was not completed on the ordered date.
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