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:
Failure to Communicate Ordered Skin Scraping to Lab A resident with suspected advanced scabies had a dermatologist order a skin scraping along with scabies medications, but the specimen was not documented as sent to the lab and no result was found in the chart. The TN stated she performed the scraping and placed the specimen in the treatment cart, but forgot to enter the order into the EMR, so the lab was not notified unless staff called. The record showed the order was later entered and backdated, while the resident received ivermectin, prednisone, permethrin, and betamethasone for scabies.
A resident with renal insufficiency, dialysis dependence, and anemia had a critical low Hgb reported, but the facility did not document completion of ordered weekly CBC labs, refusal of the draw, or follow-up with the provider. The resident said he wanted labs drawn on dialysis days, and staff noted the draw was not documented as done or declined, with no documented coordination with the dialysis unit.
A resident who was cognitively intact and had diabetes mellitus complained of urinary discomfort, and a CNP ordered a UA flex to culture to rule out a UTI. After the UA results were reviewed, the physician ordered Macrobid pending C&S results, but there was no documented evidence that the urine C&S was obtained as ordered; the ADON confirmed it was not obtained.
Missed Keppra Lab Monitoring: A resident with epilepsy and severe cognitive impairment did not have the ordered Keppra level drawn every 3 months. The care plan called for lab monitoring of seizure meds, but the last documented Keppra level was months earlier, and both ADONs acknowledged the monitoring should have occurred sooner. An active order later discontinued routine labs after hospice admission.
Failure to complete ordered lab and diagnostic testing. A resident's UA and culture were ordered but not documented as collected, and staff interviews showed confusion and missed follow-through on the specimen. In a separate case, a resident with shoulder pain had a STAT right shoulder x-ray ordered, but the TAR showed it as completed even though no diagnostic result was documented; the DON said the x-ray was not actually done and a new LPN had checked off the order in error.
Failure to obtain ordered laboratory tests. A resident with polycythemia vera and GI surgical aftercare had a physician order for weekly CBC and CMP draws on Sundays, but the EMR showed no results for two scheduled draws. An LPN could not find the lab results in the system, and the DON stated the nurse did not enter the orders, so the resident missed the ordered lab draws.
Failure to Communicate Ordered Skin Scraping to Laboratory
Penalty
Summary
The facility failed to ensure that a physician-ordered skin scraping and specimen collection for a resident suspected of scabies was communicated to the laboratory on 6/18/2026. Resident 3 was admitted with diagnoses including muscle weakness, difficulty walking, and hepatitis, and the history and physical indicated the resident had the capacity to understand and make decisions. The MDS dated 6/8/2026 indicated moderately impaired cognition. On 6/18/2026, the dermatologist’s physician order sheet included diagnoses of dermatitis and medication orders for betamethasone, ivermectin, permethrin, and prednisone, along with an instruction to perform a skin scraping. The interdisciplinary progress note documented that the resident was assessed by the dermatologist with confirmed advanced scabies, with widespread scaling, erythematous lesions, and pruritus, and noted the resident was high risk for transmission due to advanced scabies. Medication and treatment records show ivermectin, prednisone, permethrin, and betamethasone were administered beginning 6/19/2026. The resident’s record did not contain documented evidence that the skin scraping specimen was sent to the laboratory on 6/18/2026 as ordered, and there were no documented results of the skin scrape in the medical record. The order audit report later showed a skin scrape order created on 6/23/2026 and backdated to 6/19/2026 by the treatment nurse. During interview, the treatment nurse stated she performed the skin scraping on 6/19/2026 and placed the specimens in the treatment cart, but was not sure whether laboratory staff collected them. She also stated she forgot to input the order into the medical record on 6/19/2026 and that, because the order was not entered, the laboratory would not have been notified unless staff called. She further stated there was no documented evidence that the laboratory was informed, and that when she called the laboratory, she was told there were no orders for a skin scraping specimen to be collected on 6/19/2026.
Failure to Coordinate Ordered CBC Draws for a Dialysis Resident
Penalty
Summary
The facility failed to coordinate ordered blood draws for a resident with renal insufficiency, dependence on dialysis, and anemia. The resident’s admission MDS indicated he was cognitively intact and able to communicate his wishes. On 6/8/26, the resident had a critical hemoglobin value of 6.9 reported to the facility, and the provider was updated. The record then lacked evidence of subsequent blood draws after 6/15/26, despite a weekly CBC being prepared for 6/22/26. During interview, the resident stated he felt good, denied nausea or vomiting, and reported being tired after dialysis. He stated his hemoglobin had been checked at dialysis and that he had asked for lab draws to be done on dialysis days because access was already being used, but the record lacked documentation that the lab work had been attempted and declined by the resident. The documentation also lacked evidence of follow-up with the dialysis facility to arrange labs during dialysis or follow-up with the provider when the ordered draw was not completed. The HUC, RN/UM, dialysis RN, and DON all identified that the lab draw was not documented as completed or refused and that there was no documented follow-up with the provider.
Failure to Obtain Ordered Urine Culture and Sensitivity
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered by the physician for one resident. Facility policy stated that the day shift unit nurse would fill out and send laboratory requests for newly ordered laboratory tests, and that the facility would provide or obtain laboratory services to meet residents’ needs and promote the quality and timeliness of those services. Resident 43 was cognitively intact, required assistance with daily care needs, and had a diagnosis of diabetes mellitus. A Certified Nurse Practitioner note documented that the resident complained of urinary discomfort and ordered a UA flex to culture to rule out a UTI. A nurse’s note later documented that the physician was notified of the urinalysis results and ordered Macrobid pending culture and sensitivity results. Review of the resident’s May 2026 lab results showed no documented evidence that a urine C&S was obtained from the urine sample as ordered, and the Assistant Director of Nursing confirmed that the urine C&S was not obtained.
Missed Keppra Lab Monitoring
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of one resident who had epilepsy and severe cognitive impairment. The resident’s care plan directed staff to give seizure medications as ordered and monitor labs, including reporting subtherapeutic or toxic results to the physician. A physician order dated 11/10/2023 required a Keppra level every 3 months, but the last documented Keppra level was drawn on 12/20/2025, and no subsequent level was found in the record for the expected March and June 2026 monitoring periods. The resident’s physician orders showed ongoing Keppra use, with the most recent revision on 06/04/2026 for levetiracetam 500 mg/5 mL, 5 mL by mouth four times daily for epilepsy. Although an active order on 06/10/2026 discontinued all routine labs after hospice admission, staff interviews indicated the resident should have had the Keppra level checked every three months before that change. The ADONs stated they were not sure how often epilepsy medication labs were supposed to be drawn or what the therapeutic range was, and both acknowledged the resident’s last Keppra level had been in December 2025.
Failure to Complete Ordered Lab and Diagnostic Testing
Penalty
Summary
The facility failed to provide ordered laboratory testing for a resident whose physician ordered a urinalysis and culture to be collected on 06/11/2026. The laboratory documentation did not show that the urinalysis and culture and sensitivity were completed. During interviews, an LPN stated she saw the order, asked the resident about symptoms, and called the provider because she did not see results in the system. The APRN stated the resident was stable and the UA could be discontinued, and also said there was no set time for collection but expected nurses to attempt collection and contact the provider if unable to obtain the specimen. The ADON stated she missed the UA order, and two physicians stated the nurses should follow the orders and collect the specimen; one physician said no one had called regarding the specimen. The facility also failed to complete an ordered diagnostic x-ray for another resident with increased bilateral shoulder pain, worse on the right. A progress note documented that an x-ray would be obtained, and a physician order specified a STAT portable right shoulder x-ray with 3 views. The TAR showed the x-ray as completed, but the diagnostic results did not document a right shoulder x-ray. The DON stated the x-ray was not completed as ordered and explained that a new nurse checked off the order as if acknowledging it, which caused the order to disappear. An APRN stated the resident's pain was more chronic and that no harm was caused, and an LPN stated she had been under the wrong impression that the one-time order was to be checked only if actually done.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide laboratory services as ordered by a physician for Resident #1. A physician ordered weekly CBC and CMP blood draws on Sundays, but the resident’s electronic medical record did not show results for the scheduled draws on 05/31/26 or 06/07/26. The resident was admitted with diagnoses including polycythemia vera and surgical aftercare of the gastrointestinal system. During interview, an LPN stated nurses entered lab orders into the laboratory provider’s website and the provider obtained blood draws in the facility, but no CBC or CMP results could be found for the resident. The DON stated the resident was supposed to have weekly CBC and CMP testing on Sundays, did not see the results in the system, and later stated the facility nurse did not enter the orders, resulting in the missed laboratory draws.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.