Failure to Complete STAT Laboratory Test as Ordered
Summary
The facility failed to ensure that a STAT laboratory test was completed as ordered by the physician for one resident. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, atrial fibrillation, and aortic insufficiency, was admitted to the facility and later expired there. On the day of the incident, the resident experienced a change in condition, including weakness, abdominal discomfort, diarrhea, and inability to eat. The provider was notified and gave orders for STAT CBC, CMP, and KUB tests, as well as to hold lactulose and consult infectious disease. Documentation indicated that the blood draw and KUB were completed, but the timing and process of the STAT order were inconsistent and unclear. Review of the laboratory results and facility documentation revealed discrepancies in the collection and reporting times. The STAT lab order was placed in the early afternoon, but the blood was drawn earlier in the morning as part of a routine sweep, not in response to the STAT order. The phlebotomist processed the morning blood as a STAT after the order was received, and the sample was dropped off at the lab in the afternoon. The results were not reported to the facility until the evening, well beyond the facility's defined four-hour window for STAT labs. Additionally, the requisition form for the lab was incomplete, lacking collection date, time, and draw site, and had illegible patient information. Interviews with nursing staff and administration confirmed confusion regarding the facility's policy and timeframes for STAT labs. Staff provided varying accounts of the expected turnaround time, ranging from four to six hours, and acknowledged inconsistencies in the process. The facility's policy required STAT orders to be completed as soon as possible within defined timeframes, but the actual practice did not align with this standard. The failure to complete the STAT laboratory test as ordered by the physician constituted a deficiency in providing timely, quality laboratory services to meet the needs of the resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with overactive bladder and complaints of dysuria had an order for a one-time UA C&S, along with care plan interventions for labs per orders and monitoring for UTI. Staff did not attempt to obtain the urine specimen until five days after the order, when an LPN’s initial straight cath attempt was unsuccessful due to positioning and a subsequent attempt was refused by the resident, who requested a bedpan instead. There was no documentation of earlier collection attempts, no evidence that the provider was notified of the refusal, and no record that the ordered UA C&S was ever completed, despite facility policy requiring timely completion of ordered lab services.
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.
Failure to Obtain Ordered UA C&S for Resident with Dysuria
Penalty
Summary
The facility failed to ensure that a urinalysis with culture and sensitivity (UA C&S) was obtained as ordered for a resident with risk factors for urinary tract infection (UTI). The resident was admitted with diagnoses including spinal stenosis and radiculopathy and had a care plan indicating risk for bladder incontinence, skin breakdown, and UTI due to overactive bladder, with goals to minimize risk of septicemia through prompt recognition and treatment of UTI symptoms. An order dated 10/17/25 directed that a UA C&S be obtained one time for dysuria. A subsequent care plan dated 10/20/25 documented that the resident was at risk for UTI due to complaints of dysuria, with interventions including encouraging fluids, obtaining labs per orders, and taking vitals as ordered or per facility protocol. Nursing documentation showed that on 10/22/25 at 10:00 A.M., an LPN attempted to obtain a urine specimen via straight catheterization but was unable to do so due to the resident’s positioning, and planned to attempt again after repositioning. At 10:30 A.M. the same day, after repositioning, the resident yelled that she did not want to be straight cathed and requested to use a bedpan for the sample, then refused. There was no evidence in the medical record of any attempts to collect the urine sample prior to 10/22/25, no documentation that the provider was notified of the resident’s refusal, and no evidence that the ordered urine test was ever obtained. The PA who ordered the UA C&S confirmed there were no results in the record and stated he would have expected the sample to be collected as quickly as possible. The DON confirmed that the order was given on 10/17/25 and that collection was not attempted until five days later, contrary to the facility’s laboratory services policy requiring labs to be completed and results provided within normal timeframes for appropriate intervention.
Plan Of Correction
1. Resident #8 had a urinalysis collected on 10/23/26 by Ohio Health Hospital and received treatment as ordered by the physician. 2. Like Residents are identified as residents who have received orders for a urinalysis. An audit will be completed by the Director of Nursing or designee for residents who have received an order for a urinalysis in the past 30 days utilizing the Laboratory Services Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Laboratory Services Policy to ensure urinalysis tests are obtained and results are provided within timeframes normal for appropriate intervention. This education will be completed on or before 5/13/26. 4. Utilizing the Laboratory Services Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of all urinalysis ordered within the last 7 days, weekly for four weeks beginning 5/14/26 to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. Noncompliance noted during the audits will be corrected with urinalysis obtained, physician notified of results and physician orders were carried out as appropriate. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the
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.
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