Failure to Implement Laboratory Orders for Residents
Summary
The facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. Resident 25, who was admitted with acute kidney failure, anemia, severe obesity, and Type 2 diabetes, did not have a complete blood count (CBC), complete metabolic panel (CMP), and Hemoglobin A1C (Hgb A1C) drawn as ordered every three months. This oversight was confirmed during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the tests were not conducted in February, preventing the physician from identifying any potential issues with the resident's blood work. Similarly, Resident 42, who was admitted with Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease, did not have a CMP conducted in September and December as ordered. The resident's care plan emphasized the importance of obtaining and monitoring laboratory work to prevent poor food intake, weight loss, and dehydration. During an interview, the LVN confirmed that the CMP was not done, which could have prevented the doctor from detecting any abnormal results. Resident 100, diagnosed with respiratory failure, epilepsy, and polycystic kidney disease, was supposed to have monthly Keppra level blood draws to monitor therapeutic levels and prevent seizures. However, the last recorded draw was in November, with subsequent months missed. A Registered Nurse (RN) confirmed the oversight, acknowledging that the lack of blood draws could worsen the resident's epilepsy disorder. The facility's policy and procedure indicated the responsibility for ensuring timely laboratory services, which was not adhered to in these cases.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 25 and Resident 42 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. On 3/12/25, Resident 100 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on active resident lab orders to ensure all residents are receiving their labs as ordered, unless otherwise refused. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/26/25, the Director of Nursing (DON) in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Laboratory, Diagnostic and Radiology Services," with emphasis on laboratory, diagnostic, and radiology services being provided to meet resident needs and the facility being responsible for the quality and timeliness of services provided by the laboratory. The in-service also included that laboratory services ordered are documented on the 24-hour report or electronic health record, to ensure that services are coordinated, and results are received, with notification of results to the Primary Physician including any refusals. The Medical Records Director will audit residents' lab orders daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving lab draws as ordered, unless otherwise noted by a refusal. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. The measures to prevent recurrence include the same in-service training and ongoing audits as described above. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing laboratory services as ordered for three months or until compliance is met.
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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