Failure to Conduct Timely Lab Test Leads to Hospitalization
Summary
The facility failed to obtain timely laboratory services as per physician's orders for a resident, leading to an Immediate Jeopardy situation. The resident, who had been prescribed Depakote for dementia and anxiety disorder, required a valproic acid level test ordered by their nurse practitioner. However, the test was not conducted, resulting in the resident being hospitalized with valproic acid toxicity. The resident was admitted to the hospital after being observed as lethargic and unresponsive, with a valproic acid level significantly above the normal range. The facility's Director of Nursing (DON) acknowledged that routine labs were scheduled for specific days, but there was no documented evidence that the lab order was executed. The consulting pharmacist emphasized the importance of monitoring valproic acid levels due to the risk of toxicity. Interviews with facility staff revealed a lack of explanation for the failure to conduct the test. The Chief Operating Officer (COO) and DON were informed of the Immediate Jeopardy, and the COO was responsible for quality improvement efforts. Despite the CEO's disagreement with the Immediate Jeopardy classification, no additional evidence was provided to dispute the findings.
Removal Plan
- A daily audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
- Education will include the physician and their extenders, clinical managers, and facility nurses. Nurses will receive this in-service prior to their next scheduled shift.
- Education started immediately.
- Daily monitoring will begin of any lab orders, old or new, making sure the order has been accurately and successfully carried out and that the results have been communicated to the medical doctor or nurse practitioner office.
- The Director of Nursing or her designee will review lab orders in point click care, lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
- Daily review of labs will continue for one month after such time this will be reviewed weekly in the high-risk meeting.
- Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
- Lab orders will be added as one of the agenda items to be discussed during morning stand up meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a seizure disorder, vascular dementia, and liver disease had physician orders and hospital discharge instructions for Valproic Acid level monitoring, but the facility failed to ensure these labs were obtained or documented over several months. No Valproic Acid results were found in the record, and progress notes lacked documentation of any lab refusals or physician notification, despite the care plan requiring therapeutic drug monitoring. The DON confirmed there were no recent lab results or refusal forms, while an LPN reported being told the resident was combative and that blood draws were unsuccessful, with no corresponding documentation to support these reports or show follow-up on the repeated lab orders.
Facility staff failed to obtain physician-ordered laboratory tests for two residents. For one resident, a scheduled Vancomycin trough level was ordered to begin on a specific Monday but no corresponding lab result was found in the clinical record, and the DON could not provide the missing result. An LPN described a process in which lab orders are entered into the computer, transcribed into a lab communication book, verified by night shift, and then drawn by an outside lab, but no laboratory services policy was produced. For another resident, ordered labs due on a specific date were not completed as ordered, were performed a day late, and there was no documentation explaining the delay, as confirmed by the DON.
A resident receiving Dilantin for seizure prevention had physician orders for specific morning and evening doses. A nursing note documented an elevated Dilantin level and that the PCP was notified, with an order to hold the medication and redraw labs on a specified day. Review of laboratory records showed no documentation that the ordered follow-up lab was obtained. In interviews, an LPN and the DON both acknowledged the lab should have been drawn, but there was no record it was completed.
A resident with myeloblastic leukemia, cognitively intact and requiring weekly CBC tests to monitor her condition, did not receive labs as ordered. After the resident’s daughter/POA notified staff that weekly CBCs were needed and the provider entered the order, labs were only drawn on three occasions with significant gaps between draws. The DON reported that a nurse’s order-entry error initially prevented weekly labs from being completed, and that even after correction, the lab technician failed to perform scheduled draws on multiple dates. The daughter reported that the lab technician was not showing up or was missing the resident, and the Administrator acknowledged there was no laboratory policy in place.
A resident with chronic kidney disease, diabetes, anemia, polyneuropathy, and newly diagnosed congestive heart failure was readmitted from the hospital and evaluated by an NP for shortness of breath and abdominal fullness. The NP ordered a CBC with differential, BMP, and BNP/NT proBNP to monitor the resident’s condition, expecting the labs to be drawn at the next routine lab visit. The contracted lab’s phlebotomist signed daily lab tracking forms on multiple days, and facility staff interpreted these signatures as confirmation that the labs had been completed, despite minimal or unclear notations such as a single "unable" entry and no documented refusals. The resident reported that she had not had blood drawn and saw no evidence of venipuncture, and the Unit Manager later confirmed that the ordered labs were not actually obtained until several days after the original order, resulting in a delay in completing the provider-ordered testing.
A resident with metabolic encephalopathy and behavioral disturbances had physician orders for a CBC and CMP to be completed on a specified date, but the tests were not entered into the lab system and were delayed several days. The Treatment Administration Record inaccurately reflected that the labs had been done earlier than ordered, while actual lab results were not obtained until later and showed abnormal WBC, creatinine, and BUN levels. The DON reported that the missed lab order was only discovered during an audit and confirmed that the laboratory orders were not followed in a timely manner.
Failure to Complete and Document Ordered Valproic Acid Lab Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests for monitoring an anticonvulsant medication were completed and followed up in a timely manner for one resident. The resident had medical diagnoses including seizures, vascular dementia, and liver disease, and a care plan intervention requiring lab tests for therapeutic monitoring of medication levels per MD orders, with MD notification of subtherapeutic or toxic levels. Hospital discharge instructions directed that a Valproic Acid level be obtained one week after discharge, and subsequent physician orders on multiple dates required Valproic Acid laboratory values. However, the resident’s medical record contained no documentation that these laboratory tests were ever obtained and no lab results were present. From the time of the resident’s hospital discharge through the review period, progress notes contained no documentation of the resident refusing blood draws or of physician notification regarding any refusals. The DON confirmed there were no lab results on file for the resident since several months prior and no documentation of refusals or reasons why the labs were not performed, despite a facility policy requiring that labs be completed per MD order and abnormal or immediate labs be relayed to the physician. An LPN reported that staff had informed her the resident was very combative and that blood specimens could not be obtained, and stated she notified the physician, who instructed staff to continue attempts; however, there was no corresponding documentation of these refusals or follow-up in the record. The facility was still attempting to determine why the ordered labs from December had not been completed.
Failure to Obtain Physician-Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to obtain physician-ordered laboratory tests for two residents. For one resident (R6), the clinical record showed a physician’s order dated 2/11/26 for a Vancomycin trough level to start on 2/16/26 and to be obtained every Monday. Review of the resident’s clinical record did not contain laboratory results for the Vancomycin trough level that was due on 2/16/26. On 2/20/26, the DON stated she could not provide the laboratory results for that date. An LPN later explained that lab orders are entered and scheduled in the computer system, then written in a lab communication book; the night shift nurse is to verify labs due the next day and place a face sheet in the lab communication book, and an outside lab company obtains the lab on the due date. The facility did not provide a policy regarding laboratory services. For another resident (R24), the facility staff did not obtain laboratory tests as ordered by the physician. The physician orders included labs that were to be completed on 1/20/2026, but the DON confirmed on 2/20/2026 that these lab tests were not completed as ordered and that there was no documentation explaining why the labs were done a day late. The Administrator, DON, General Manager, and Senior Director of Nursing Services were informed of these concerns during the survey, and no additional information was provided prior to exit.
Failure to Obtain Ordered Follow-Up Dilantin Level
Penalty
Summary
The facility failed to provide timely, ordered laboratory services for a resident receiving Dilantin for seizure prevention. The resident had physician orders dated 09/01/25 for Dilantin 100 mg, one capsule in the morning and two capsules in the evening. A nursing note dated 11/24/25 documented a Dilantin level of 44.4 and that the primary care provider was notified, with a new order to hold Dilantin and redraw labs on Wednesday. Review of the resident’s November 2025 laboratory results showed no documentation that the ordered follow-up lab was obtained. During interviews on 03/04/26, an LPN stated the lab should have been obtained on 11/26/25 and confirmed there was no record it was done, and the DON also stated the lab should have been obtained on that date. This deficiency occurred in the context of a survey sample of five residents reviewed for falls, with the ADON identifying that 70 residents resided in the facility at the time of the survey.
Failure to Provide Ordered Weekly CBC Labs for Leukemia Monitoring
Penalty
Summary
The facility failed to provide ordered weekly laboratory services for a resident with myeloblastic leukemia. The resident was admitted with a diagnosis of myeloblastic leukemia, a condition associated with low hemoglobin and red blood cell counts, and was cognitively intact with a BIMS score of 13. On a documented date, the resident’s daughter and power of attorney informed the facility that the resident should be receiving weekly CBC tests, and the provider ordered weekly CBC labs accordingly. A subsequent health status note indicated that the resident would begin going to a local hospital for her weekly CBC draws due to past issues with the current lab services. The resident later stated that her daughter managed her labs but believed some had been missed, and the daughter reported that the lab technician was either not showing up or missing the resident, and that the facility had indicated it was not a big deal that the labs were not drawn. Laboratory records showed that the resident’s CBCs were drawn on three dates only, with no lab drawn on or shortly after the date the weekly order was initiated, and after a draw on a later date, there was nearly a three-week gap before the next lab was obtained. The DON stated that the initial failure to complete weekly labs after one of the draws was due to a nurse’s error when entering the order, and that after this error was corrected, the lab technician still failed to draw the resident’s labs on several occasions, specifically missing scheduled draws on two identified dates. The DON confirmed that these labs were intended to monitor the resident’s leukemia. The Administrator stated that the facility did not have a laboratory policy.
Failure to Ensure Timely Completion of Ordered Laboratory Tests After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered laboratory tests were completed in a timely manner for a resident recently readmitted from the hospital with multiple serious diagnoses, including chronic kidney disease, diabetes, anemia, polyneuropathy, and congestive heart failure. After readmission, the resident was followed by a provider group in addition to her physician and was documented as cognitively intact. On 2/20/26, an NP documented that a nurse had reported the resident was short of breath without hypoxia and had a feeling of abdominal fullness, though she was functionally at baseline. In response, the NP made medication changes and ordered a CBC with differential, BMP, and BNP/NT proBNP to monitor kidney function, anemia, and infection risk. The contracted lab company provided routine lab services six days per week, with the expectation that an order placed on a Friday would be drawn on Saturday if the requisition was in the lab book. The lab’s Risk Manager explained that the phlebotomist checked a lab book organized by date, signed a lab sheet each day, and was required to notify nursing and a lead phlebotomist if unable to obtain blood two days in a row. Review of the facility’s lab tracking forms showed the resident’s name listed for labs on 2/21/26, 2/24/26, and 2/25/26. On 2/21/26, the phlebotomist initialed the form, but there was no notation of refusal or inability to draw. On 2/24/26, the form contained only the notation “unable” by the resident’s name, with no further explanation. On 2/25/26, the resident’s name and labs again appeared with the phlebotomist’s initials at the top of the page and no notation that the labs were not drawn. During this period, the resident reported that she had recently returned from the hospital with a new diagnosis of congestive heart failure, was more short of breath, and very tired. She stated that while hospitalized she had required blood and that labs were supposed to be drawn at the facility but had not been done. She recounted being told she had refused blood work while asleep on one morning, though she did not recall this, and later being told that her blood work had been completed despite having no signs of a blood draw and no recollection of it. On 2/26/26, she reported that she still had not had lab work drawn. The Unit Manager stated that when the phlebotomist signed at the top of the lab sheet without a notation by a resident’s name, staff understood that the labs had been completed, but in this case the labs ordered on 2/20/26 were not actually obtained until 2/26/26. The Administrator and Nurse Consultant confirmed that their system relied on the phlebotomist’s initials at the top of the lab sheets to indicate completion and that, based on this, they believed the labs had been done on 2/21/26 and 2/25/26, even though they had not.
Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
The deficiency involves the facility’s failure to carry out ordered laboratory tests (CBC and CMP) in a timely manner for one resident. The resident had a diagnosis of metabolic encephalopathy and behavioral disturbances. On February 4, 2026, the NP documented the resident’s condition, and a physician order was written the same day for a CBC and CMP to be completed on February 5, 2026. The February 2026 Treatment Administration Record indicated that the CBC and CMP order was entered as being done on February 4, 2026, even though the order specified testing on February 5, 2026. A review of the resident’s laboratory results showed that the CBC and CMP ordered for February 5, 2026, were not actually performed until February 11, 2026. The February 11 blood work revealed abnormal values, including an elevated WBC of 16.8, creatinine of 2.86, and BUN of 79. A physician order dated February 11, 2026, included an order for 0.45% sodium chloride IV hydration. During an interview, the DON stated that the February 5 blood work order had not been entered into the laboratory system and therefore was not completed as ordered, and that this missed blood work was not identified until an audit on February 10, 2026. The DON confirmed that the laboratory order for February 5, 2026, was not followed in a timely manner.
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