Deficiency in Laboratory Services and Supplies
Summary
The facility failed to ensure an organized system and adequate supplies for timely and accurate laboratory services for four residents. Observations revealed a lack of necessary supplies for in-house blood draws. Resident R1 had a physician's order for a Comprehensive Metabolic Panel (CMP) and a Complete Blood Count (CBC) with differential, but only the CBC was drawn, and the CMP was not completed. Resident R2 had a standing order for potassium level checks, but there was no evidence of these tests being conducted as ordered in December. Resident R3's orders for a CMP and CBC with differential were not fulfilled, and Resident R4's redraw for ACTH and BNP tests was not completed as requested by the laboratory. The Director of Nursing confirmed the deficiencies, attributing them to the absence of an organized laboratory system and insufficient supplies. The facility's laboratory binder contained incomplete order sheets for all four residents, further indicating a lack of proper documentation and follow-through on laboratory orders. These findings highlight the facility's failure to meet the regulatory requirements for providing or obtaining necessary laboratory services to meet the residents' needs.
Plan Of Correction
Twinbrook Healthcare recognizes the importance of timely and accurate laboratory services to meet the needs of our residents. Following identification of the deficiencies cited, immediate corrective actions were taken to address the issues related to lab supply shortages and the organization of laboratory services. The laboratory supply room was promptly restocked to ensure an adequate supply of materials necessary for in-house blood draws. Additionally, nursing staff were re-educated by Director of Nursing (DON)/designee on the process for monitoring and replenishing laboratory supplies, and supply levels will be audited weekly for four [4] weeks and monthly for two [2] months by the Director of Nursing (DON) or designee to ensure availability of necessary items. Regarding the residents cited in the findings, the attending physicians for Residents R1, R2, R3, and R4 were immediately notified of the missed laboratory draws, and the labs were obtained and completed. A thorough audit of all current laboratory orders for facility residents was conducted to ensure compliance, and no further issues were identified. Weekly reviews of lab requests will be conducted via use of electronic medical records generated reports of physician ordered labs three (3) times a week for four [4] weeks, followed by monthly reviews for two [2] months, to confirm that laboratory tests are being ordered, documented, and completed as required. All nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. This education, conducted by the DON or designee, emphasized the importance of adhering to physician orders, maintaining accurate documentation, and ensuring timely completion of all laboratory tests. Education completed by 1/20/2025, and compliance will continue to be reinforced through ongoing education during regular staff in-service sessions. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Finally, it has been verified that no adverse reactions occurred as a result of the missed laboratory draws for the residents cited in this finding. Full implementation of this Plan of Correction will be completed on 1/20/2025.
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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