Failure to Follow Lab Test Orders for Resident with UTI and Behavioral Issues
Summary
The facility failed to ensure that physician orders and recommendations for laboratory tests were followed for a resident who was admitted with acute encephalopathy and a urinary tract infection. The resident, who had a history of UTI with delirium, exhibited various behaviors such as increased anxiety, hallucinations, and aggression. Despite the psychiatric nurse practitioner's repeated recommendations to obtain a urine analysis and other lab tests to rule out infectious or metabolic causes of the resident's altered mental status, these tests were not conducted. The resident's clinical records showed ongoing behavioral issues, including aggression towards staff and other residents, refusal of meals and medications, and attempts to leave the facility. The psychiatric nurse practitioner made multiple visits and consistently recommended lab tests to assess the resident's condition, but these recommendations were not addressed by the facility. The resident's condition did not improve, and he was eventually transferred to the hospital, where he was diagnosed with an acute kidney injury and treated for a urinary tract infection. Interviews with the Unit Manager confirmed that the urine analysis ordered by the physician and recommended by the nurse practitioner on several occasions was not completed. This oversight in following medical orders and recommendations contributed to the resident's continued behavioral issues and eventual hospitalization.
Plan Of Correction
The Facility does and shall ensure that routine and emergency Lab services were provided for all residents to meet their health needs. All residents will be reviewed for Lab orders to meet health needs. Education has been done. All nursing staff have/will be educated regarding timely lab services for all residents. Monitoring and random check will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and on-going monitoring will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Delayed urine specimen processing and lab submission: A resident with diabetes, urinary retention, and incontinence had a urine culture and urinalysis ordered after abnormal UA findings. The resident refused collection multiple times, then an RN collected the specimen and refrigerated it, but there was no documentation that the lab was contacted for pickup for several days. The specimen later resulted as contaminated, and a later urine sample was also contaminated and could not be processed.
Failure to obtain an ordered BMP for a resident with recent hyponatremia and multiple neurologic and fracture diagnoses. The resident returned from the hospital with discharge instructions for a BMP, but the lab result was not in the chart. The DON said the resident refused blood draws and the MD was aware, but there was no documentation of refusal or MD notification; the resident denied refusing labs, an RN confirmed no refusal, and the MD stated being unaware the BMP order had not been completed.
A resident with ESRD, CHF, cirrhosis, and A-fib had a physician order for daily PT/INR testing for two weeks due to increased results, but the MAR/TAR showed missed lab draws and the order was later discontinued. Nursing notes stated the lab could not come to the facility that weekend, and the DON, Facility Administrator, and RN reported the contracted lab service was only available once weekly and the hospital lab could not come to the facility.
Delayed urine specimen processing affected two residents with suspected UTI. One resident’s UA specimen could not be processed because the sample was not identifiable, and the replacement specimen and results were delayed. Another resident’s urine sample sat in the lab pickup box until several days later, and the culture was not performed because the specimen exceeded stability requirements.
A resident’s ordered hemoglobin A1c testing was missed twice in a row, with no documentation that the January and April labs were obtained. An LPN acknowledged the order was not followed, and the DON stated the A1c should have been collected as soon as the missing tests were identified.
A resident with critical hypokalemia did not receive a timely potassium re-check after an NP ordered the lab to be drawn by 3:00 PM. The TAR showed the order was not completed, and staff interviews confirmed the RN transcribed the order, the LPN did not obtain the draw that day, and the lab was not completed until the next day.
Delayed Urine Specimen Processing and Lab Submission
Penalty
Summary
The facility failed to ensure a urine specimen was collected, processed, and submitted to the laboratory in a timely manner for one resident reviewed for urinary tract infections. The resident had diagnoses including type 2 diabetes mellitus, thrombocytopenia, urinary retention, transient ischemic attack, and anxiety, and was cognitively intact, dependent on toileting hygiene, and always incontinent of urine. A physician ordered a urine culture and urinalysis, and when the laboratory could not perform sensitivity testing on the initial specimen because of abnormal leukocytes, the nurse practitioner ordered recollection. The resident refused urine collection multiple times on 05/21/26 and 05/22/26, though urine was eventually collected by an RN on 05/22/26 and placed in the refrigerator. The RN stated the laboratory needed to be contacted for pickup, but the record contained no documentation that the lab was contacted for specimen pickup from 05/22/26 through 05/26/26. The urinalysis report later showed three or more isolates, suggesting contamination. A subsequent urine specimen collected on 05/27/26 was also contaminated and results could not be obtained, and the nurse practitioner discontinued the urinalysis order.
Failure to Obtain Ordered BMP
Penalty
Summary
The facility failed to follow a physician order to obtain a BMP for one resident who had been hospitalized for hyponatremia and returned to the facility with discharge instructions that included a BMP to be collected on April 10, 2026. The resident’s record did not contain BMP results. The resident’s medical history included maxillary fracture, left lateral orbital fracture, hyponatremia, left-sided hemiplegia/hemiparalysis, Alzheimer’s disease, insomnia, subdural hemorrhage, metabolic encephalopathy, and depression. During interviews, the lab technician stated the resident’s last BMP had been collected in April 2025. The DON stated the lab draw process was to enter the order into the chart, send it to the lab company, and have the lab technician collect the specimen as scheduled, with results communicated to the physician. The DON later stated the resident did not have the BMP drawn because the resident refused blood draws and that the physician was aware, but there was no documentation in the resident’s record of refusal or physician notification. The resident stated the resident never refuses blood draws, and a registered nurse confirmed the resident did not refuse the blood draw on May 27, 2026. The physician later stated being unaware of the BMP order at discharge and unaware that it had not been processed or completed.
Missed PT/INR Lab Testing
Penalty
Summary
The facility failed to ensure laboratory services were provided for 1 of 3 residents reviewed for quality of care. Resident B had diagnoses including end stage renal disease, chronic heart failure, cirrhosis of the liver, and atrial fibrillation, and the most recent quarterly MDS dated 5/11/26 indicated the resident was cognitively intact and received dialysis services. Physician orders included PT/INR testing daily for two weeks due to increased results, starting 5/13/26, but the May 2026 MAR/TAR showed the lab test was not completed on 5/15/26, 5/16/26, and 5/17/26 before the order was discontinued on 5/18/26. Nurse's notes documented that the lab could not come to the facility that weekend to draw the resident's PT/INR and that the physician was aware. During interview, the DON and Facility Administrator stated the contracted lab service was unrealizable and would only come to the facility once a week, and that the facility attempted to use a local hospital lab service but hospital lab staff was unable to come to the facility. RN 4 stated the facility did not have a contract with the hospital lab. The facility later provided an outsourced lab contract that included PT/INR as STAT testing, but the ordered daily lab draws were not completed as documented.
Delayed Urine Specimen Processing and Lab Follow-Up
Penalty
Summary
The facility failed to provide timely lab services for two residents who had urine specimens collected for suspected urinary tract infection. One resident, admitted with acute pyelonephritis and cognitively intact, reported burning with urination and had a UA ordered; the specimen was sent to the lab the same day, but the facility later learned the specimen could not be processed because the resident’s name was not identifiable on the sample. A new UA order was obtained several days later, a new urine specimen was collected and sent, and the lab results were not returned to the facility until several days after that. The resident later returned to the hospital after a fall and was diagnosed with a UTI while hospitalized. A second resident, admitted with a shoulder fracture, had a provider visit note documenting suspected UTI with urine retention and an order to send a urine sample for evaluation. The urine sample was collected and placed in the laboratory box for courier pickup, but the specimen was not received by the lab until several days later. The final diagnostic report showed many bacteria in the urine and a culture was to be completed, but the culture was not performed because the specimen quality was inadequate and the urine sample exceeded the stability required for the test.
Failure to Obtain Ordered Hemoglobin A1c Testing
Penalty
Summary
The facility failed to obtain hemoglobin A1c laboratory testing as ordered for one resident who had an order dated 01/02/17 for hemoglobin A1c testing due in January, April, July, and October. Review of the resident’s laboratory results for January and April 2026 showed no documentation that the tests were obtained. A physician’s progress note dated 05/18/26 stated that an A1C was needed with the patient’s labs every 90 days and that it had been missed twice in a row. During interviews on 05/21/26, an LPN stated that lab requisitions were normally completed and labs collected on Tuesdays and Thursdays, acknowledged that the hemoglobin A1c test was not collected in January and April 2026, and stated that the physician’s order was not followed. The LPN later stated the hemoglobin A1c test was collected at 8:00 a.m. that day, and the DON stated the test should have been collected as soon as possible when the physician noticed the tests were missing.
Delayed Potassium Lab Draw
Penalty
Summary
The facility did not provide timely laboratory services for one sampled resident when a potassium re-check ordered for critical hypokalemia was not completed by the ordered time. The resident had diagnoses including paraplegia, pneumonia, diabetes, cirrhosis of the liver, and anxiety, and had intact cognition with a BIMS score of 15 out of 15. A lab result showed the resident’s potassium level was 2.7 mmol/L, and Nurse Practitioner E ordered oral potassium and a repeat potassium draw by 3:00 PM the same day. The resident’s TAR reflected the order for the potassium re-check, but it was not initialed as completed. During interviews, NP-E stated the re-check was not completed and said it was unacceptable, noting the order was given because of a critically low potassium level. RN-C stated the verbal order was received, oral potassium was given, and the lab order was transcribed, but the lab was not drawn as ordered. LPN-D stated the order did not specify a time and that by the time medication pass was completed it was after 6:00 PM, so the lab was not drawn. DON-B verified the potassium lab was drawn the next day instead of as ordered and was unsure why it was not completed on the ordered date.
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