Failure to File Lab Results in Resident's Clinical Record
Summary
The facility staff failed to file laboratory results in the clinical record for a resident, leading to a deficiency. Specifically, the results of a urinalysis with culture and sensitivity (UA C&S) and a thyroid-stimulating hormone (TSH) blood test were not included in the resident's clinical record. The resident had multiple diagnoses, including acute and chronic respiratory failure, obstructive and reflux uropathy, hypothyroidism, acute congestive heart failure, dementia, and chronic cystitis. The resident was severely cognitively impaired, as indicated by a brief interview for mental status (BIMS) score of 3 out of 15. The medical provider had ordered the UA C&S on 11/10/22 and the TSH level on 1/04/23, but the surveyor could not locate these results in the clinical record during the review. Upon request, the Director of Nursing (DON) provided the lab results for the UA C&S collected on 11/14/22 and the TSH level obtained on 1/05/23, along with eight additional lab test results that were also missing from the resident's clinical record. The lab system was not integrated with the clinical record system at the time, and the facility had to request all lab results from the lab provider. The facility was unable to provide the lab policy effective during the relevant period, and the issue was discussed with the facility management team, including the Administrator and DON, but no further information was provided before the exit conference.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
The facility failed to maintain accurate records and reconciliation of controlled substances for two residents, resulting in medication discrepancies and diversion by an LPN. In both cases, oxycodone was signed out and administered without proper documentation or resident request, and required dual signatures for narcotic counts were missing across multiple shifts.
Two residents with complex medical conditions had laboratory tests ordered, but the results were not filed in their clinical records. Staff interviews revealed that issues with the online lab portal and differences in handling STAT versus routine labs contributed to the missing documentation, as results were not consistently uploaded to the residents' medical records.
A deficiency was identified when laboratory records in a resident's medical file were found to be incomplete and lacking required dates.
Two residents did not have all required laboratory results filed in their medical records, including a missing urine culture and a missing urine microalbumin result. The ADON confirmed that these results were not present in the records and had to be obtained from external sources.
A resident with multiple chronic conditions had a physician's order for a vaginal culture due to vaginal discharge, but the resulting laboratory report was not filed in the electronic medical record. Staff confirmed that the lab results from an outside facility were not requested or uploaded as required.
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.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including acute respiratory failure with hypoxia, Crohn's disease, and hemiplegia, multiple physician orders for laboratory tests such as Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Clostridioides difficile (C-diff) were documented, but the corresponding laboratory results were not found in the resident's medical record. Nursing progress notes and physician orders confirmed that these labs were ordered and should have been completed, yet no results were available in the record during the review period. For another resident with schizoaffective disorder, diabetes mellitus with kidney complication, and chronic kidney disease, an active physician's order for Glycated Hemoglobin (HgbA1C) to be drawn every six months was present, but no laboratory results were located in the medical record. Interviews with staff revealed that STAT lab results were typically faxed and reviewed by the provider, while routine labs were accessed through an online portal and were supposed to be uploaded to the resident's medical record by medical records staff. However, issues with the online portal and differences in how STAT and routine labs were managed led to missing documentation of lab results in the residents' records.
Incomplete and Undated Laboratory Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's record. This deficiency was identified through review of documentation, which revealed that laboratory records were either incomplete or missing required dates. The lack of proper documentation was directly observed in the resident's medical record.
Incomplete Filing of Laboratory Results in Resident Records
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including Lupus, major depressive disorder, dementia, anxiety, and a history of falls, a physician's order was placed for a urine analysis with culture. While the urine analysis result was present in the medical record, the urine culture result was missing. The Assistant Director of Nursing (ADON) confirmed that the culture results had not been filed in the medical record and had to be obtained by calling the laboratory. Similarly, another resident with Alzheimer's disease, type 2 diabetes, major depressive disorder, and anxiety disorder had a physician's order for multiple laboratory tests, including a urine microalbumin. Although most test results were documented, the urine microalbumin result was not found in the medical record. The ADON stated that she had to request the hospital to send the missing result so it could be attached to the medical record. In both cases, the required laboratory reports were not filed in the residents' clinical records as required.
Failure to File Laboratory Results in Resident Record
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical record for one resident. Specifically, a resident with multiple diagnoses, including bilateral primary osteoarthritis of the knee, type 1 diabetes mellitus with diabetic polyneuropathy, anxiety disorder, and mood disorder, was admitted and later readmitted to the facility. On a specified date, a physician's assistant ordered a vaginal culture for yeast, trichomonas vaginalis, and sexually transmitted diseases due to a diagnosis of vaginal discharge. Although the order was completed, the laboratory results were not found in the resident's electronic medical record during a review. Interviews with facility staff confirmed that the lab results, which were from an outside facility, had not been requested or uploaded to the resident's record.
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