Failure to Timely Obtain Urinalysis Leads to Hospitalization
Summary
The facility failed to obtain a physician-ordered urinalysis result in a timely manner for one resident. On January 9, 2025, a Licensed Practical Nurse (LPN) received an order for a urinalysis due to the resident's decreased urinary output and foul-smelling urine. However, the LPN did not have time to collect the sample and passed the task to the oncoming nurse. The urinalysis was not collected until January 13, 2025, despite the resident's condition worsening, with urine described as dark yellow, containing sediment, and murky. The delay in obtaining the urinalysis was not communicated to the physician, as required by the facility's policy. The resident was eventually catheterized on January 13, 2025, to obtain a urine sample, which was green, thick, and foul-smelling. The resident was subsequently sent to the hospital, where they were diagnosed with a urinary tract infection and encephalopathy, requiring intravenous antibiotics. The Director of Nursing confirmed the lack of documentation for the urinalysis collection on January 9, 2025, and the Medical Director stated that lab tests should be completed the same day they are ordered unless otherwise notified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple complex medical conditions did not receive ordered urine analysis with culture and sensitivity tests. The facility failed to collect the required laboratory samples and did not document the missed tests or notify the prescribing provider. The DON confirmed the omission and lack of documentation.
A resident with multiple serious health conditions experienced a critically low potassium level, prompting a physician to order immediate potassium administration and additional lab tests. Although the RN relayed the orders to an LPN, only a basic metabolic panel was completed, and the required comprehensive metabolic panel and magnesium tests were not performed. The DON confirmed the orders were not entered into the medical record, and staff interviews revealed a breakdown in communication and follow-through.
The facility did not ensure that physician-ordered laboratory tests were completed for two residents with complex medical conditions. Despite orders for multiple labs, only some were completed, and several were not obtained or on file, as confirmed by the DON. This failure was contrary to facility policy requiring staff to process and arrange for all ordered diagnostic testing.
A resident with multiple medical conditions, including cancer, did not have laboratory tests completed as ordered by their physician. Instead, incorrect labs were drawn on one occasion, and on another, one required test was missed, resulting in the resident missing a chemotherapy treatment. An LPN confirmed the errors in lab collection during interviews.
A resident with a history of UTI and urinary retention did not have a urinalysis completed as ordered by a CNP. Although urine was collected, it was not sent to the lab, and the CNP was not notified of the missed test. The DON confirmed the lapse, and no urinalysis results were available in the medical record.
A resident receiving IV Vancomycin for osteomyelitis did not have required peak and trough lab levels ordered or drawn for three weeks, despite standard care expectations. Staff interviews confirmed the omission, and the facility lacked a policy for antibiotic lab monitoring.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered for one resident. The medical record review showed that the resident, who had diagnoses including morbid obesity, lymphedema, chronic embolism and thrombosis, and hereditary deficiency of clotting factor, was admitted and later transferred to the hospital, where they expired. The resident's care plan included interventions such as laboratory tests as ordered, particularly urine analysis with culture and sensitivity to rule out urinary tract infections. However, there were two separate orders for urine analysis with culture and sensitivity that were not completed as required. Further review of the electronic medical record revealed no results for the ordered urine analyses, and there was no documentation indicating that the prescribing provider was notified about the missed tests. Additionally, the progress notes and the resident's medical record did not contain any information regarding the facility's failure to obtain the ordered laboratory tests. The DON confirmed during an interview that the laboratory tests were not collected as ordered and that there was no documentation of this failure in the medical record.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, and an open wound. The resident had a critically low potassium level identified through laboratory testing, which prompted the physician to order immediate administration of potassium chloride and additional laboratory tests, specifically a comprehensive metabolic panel (CMP) and magnesium level. The orders were communicated by an RN to an LPN, who acknowledged understanding of the instructions. Despite these orders, only a basic metabolic panel (BMP) was completed, and the required CMP and magnesium tests were not performed. The failure was confirmed through closed record review and interviews, with the DON verifying that the orders for the additional blood work were not entered into the medical record. The LPN involved could not recall details about the potassium or the ordered blood work, and the RN confirmed that the orders were relayed but not executed. Facility policies required nurses to transcribe and execute physician orders or ensure a safe hand-off, and to contact laboratory services as needed, but these procedures were not followed in this instance.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory values were completed as ordered by the physician for two out of three residents reviewed. For one resident with multiple diagnoses including dementia, pressure ulcers, diabetes, and cerebral atherosclerosis, a wound care nurse practitioner ordered several labs (CBC, CMP, albumin, prealbumin, transferrin, and hemoglobin A1c). While the CMP was completed, the other ordered labs were not obtained or on file, as confirmed by the Director of Nursing (DON). Another resident with a history of pseudobulbar affect, stroke, depression, Alzheimer's disease, diabetes, hyperlipidemia, hypertension, anxiety, chronic kidney disease, and other cerebrovascular disease also had several labs ordered (CBC, CMP, TSH, A1c, lipid panel, ferritin, B12, and vitamin D) to be collected on a specified lab day. None of these labs were collected or on file, as verified by the DON. The facility's policy required staff to process test requisitions and arrange for testing, but this was not followed for these residents.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for one resident. Medical record review showed that the resident, who had diagnoses including malignant neoplasm of the lung, malnutrition, depression, and a history of falls, was admitted with orders from a chemotherapy physician to have specific labs drawn on a set schedule. On one occasion, instead of the required labs, only a Prothrombin Time (PT) and International Normalized Ratio (INR) were collected. On a subsequent attempt, all required labs except for the Comprehensive Metabolic Panel (CMP) were collected, necessitating another order for the CMP to be drawn on a later date. Interviews with the resident and an LPN confirmed that the labs were not collected as ordered, resulting in the resident missing a chemotherapy treatment. The LPN acknowledged the error in the lab collection process and described the steps taken to attempt to correct the issue, including ordering a STAT lab and reordering the missing test. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for laboratory testing.
Failure to Timely Obtain and Process Ordered Urinalysis
Penalty
Summary
The facility failed to timely obtain and process a urinalysis as ordered by a certified nurse practitioner (CNP) for a resident with a history of urinary tract infection (UTI) and urinary retention. The resident, who was cognitively intact and required assistance with toileting, had an order to remove an indwelling catheter and perform straight catheterization every four to six hours. On a subsequent date, the CNP ordered to hold Cipro, start intravenous Ceftriaxone, and obtain a urinalysis due to ongoing infection concerns. However, the CNP was not informed that the resident was not receiving Cipro as ordered, nor that straight catheterization was not being performed as prescribed, despite evidence of significant urine retention. Interviews and record reviews confirmed that although urine was collected for the urinalysis, it was never sent to the laboratory, and no results were available in the medical record. The DON confirmed the urine sample was not processed and could not provide a reason for this failure. The CNP was not notified that the urinalysis was not completed, and only became aware of the issue during the investigation. This deficiency was identified during the course of a complaint investigation.
Failure to Obtain and Monitor Vancomycin Lab Levels
Penalty
Summary
The facility failed to ensure that blood draw orders for Vancomycin peak and trough levels were obtained and completed for a resident who was receiving intravenous Vancomycin for osteomyelitis. The resident, who had multiple diagnoses including acute osteomyelitis, peripheral vascular disease, diabetes mellitus type two, and abscess of the right ankle and foot, was admitted and received Vancomycin without any corresponding lab orders for monitoring drug levels. Review of the medical record and nursing notes confirmed that no Vancomycin peak or trough levels were ordered or documented during a three-week period of administration. Interviews with facility staff, including an LPN, a physician assistant, the consulting pharmacist, and the Director of Nursing, confirmed that the standard of care for Vancomycin administration was not followed, as regular lab monitoring was expected but not performed. The pharmacist noted that hospital discharge instructions included weekly trough levels, but these were not implemented upon admission. The facility also lacked a policy regarding lab draws and monitoring for antibiotics, contributing to the oversight.
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