Failure to Obtain STAT Laboratory Services as Ordered
Summary
The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.
Plan Of Correction
Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Ordered Lab Tests: Two residents did not receive ordered lab services. One resident with dementia and Alzheimer's disease had a UA with C&S ordered, but no urine sample was obtained and there was no documentation the test was completed; the DON said the physician was not notified. Another resident with diabetes mellitus and CKD had ordered CMP, CBC, and lipid panel monitoring that was not completed as ordered, and the DON stated the lab tests had not been done.
Failure to obtain ordered ammonia labs for a resident with epilepsy, hepatic encephalopathy, and alcoholic cirrhosis. The resident had standing orders for ammonia and anticonvulsant levels, but the record lacked an ammonia result after the lab was ordered, and later documentation showed no ammonia level for an extended period. The DON stated the lab missed the draw and that some later lab orders were not entered into MatrixCare.
The facility did not maintain or provide a written agreement with a CLIA-certified laboratory to ensure timely access to required lab services when on-site services were not available. During surveyor review of facility documents and policies, no contract or agreement for laboratory services could be found. The Administrator reported being unable to locate the laboratory services contract, stating that important document binders had been moved during a recent facility-wide evacuation, and the facility was unable to produce any documentation showing how lab services were formally arranged.
A resident with failure to thrive and recurrent UTI symptoms had a physician order for a urinalysis and urine C&S, but the specimen was not obtained and no results were found in the record. The DON later learned the lab did not have the urine specimen and stated there was no indication the facility followed up with the lab regarding the ordered test.
Failure to obtain ordered urine culture after a resident fall. A resident with a history of cardiac arrest, DM2, neuropathy, HTN, anxiety, and muscle weakness was found on the floor next to her bed. The IDT recommended CBC, BMP, UA, and C&S; the CBC, BMP, and urine testing were completed, but the C&S was not completed even after the lab indicated a culture was needed and another urine sample was recommended.
A resident with an elevated potassium level had physician orders for repeat lab tests, but staff failed to obtain the required laboratory studies on the specified dates. The DON confirmed that the ordered lab work was not completed, and clinical records lacked evidence of the tests being performed.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure ordered laboratory services were completed for 2 residents. One resident with diagnoses including dementia and Alzheimer's disease had a physician order for a urinalysis with culture and sensitivity, but the resident was incontinent and a urine sample was not obtained; there was no documentation that the sample was later collected or that the UA with C&S was completed, and the DON stated the physician had not been notified that the test was not completed. Another resident with diagnoses including diabetes mellitus and chronic kidney disease had physician orders for monthly CMP and CBC testing and a lipid panel every 3 months, but the last CMP and CBC results in the record were from earlier in the year and the last lipid panel result was also not current; the DON stated the laboratory tests had not been completed as ordered and that the order was supposed to be changed to every 3 months but was not entered by the Unit Manager.
Failure to Obtain Ordered Ammonia Laboratory Testing
Penalty
Summary
The facility failed to obtain ordered laboratory testing for a resident with epilepsy, cystic kidney disease, hepatic encephalopathy, and alcoholic cirrhosis who had standing orders for ammonia, divalproex, and levetiracetam levels every second Monday of February, May, August, and November. The resident’s record showed ongoing monitoring for elevated ammonia levels and medication management involving levetiracetam, divalproex, lactulose, and rifaximin. A care plan identified the resident as at risk for functional decline due to toxic encephalopathy and included interventions to obtain lab draws as ordered and send them to the physician for review. The record showed that after neurology raised concern about continued divalproex use because of chronically elevated ammonia levels, an ammonia level was ordered for a lab draw, but the 7/10/25 lab review lacked an ammonia result. Subsequent notes documented additional ammonia orders and provider review, yet the clinical record lacked documentation of an ammonia level from 7/7/25 through 8/10/25. During interviews, the DON stated the lab did not draw the ammonia level on 7/10/25 and that the requisition had been entered in MatrixCare but the lab missed it. The DON also stated the facility had not entered orders for ammonia labs ordered later, and the ADON was responsible for following up on lab draws and entering lab orders.
Failure to Maintain Written Agreement for Laboratory Services
Penalty
Summary
The facility failed to maintain and provide a written agreement with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory to ensure timely availability of required laboratory services when such services are not provided on-site. During document and policy review, surveyors were unable to identify any written agreement or contract verifying arrangements for laboratory services. In an interview, the Administrator reported being unable to locate the requested laboratory services contract at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation. The facility ultimately could not produce documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Failure to Obtain Ordered Urinalysis and Urine Culture
Penalty
Summary
The facility failed to ensure laboratory services were provided for one resident when a urinalysis with culture and sensitivity ordered by the physician was not obtained. Resident #2, who was admitted in July 2025 with a diagnosis of failure to thrive, was seen by the physician for recurrent urinary tract infection symptoms and dysuria. On 11/11/25, the physician ordered a urinalysis and a urine culture and sensitivity, and a nursing progress note on 11/12/25 documented that the resident had been seen the previous evening with an order to collect urine and send it for culture and sensitivity. Review of the paper and electronic medical record on 1/15/26 did not show urinalysis results from November 2025. During an interview on 1/20/26, the DON stated he contacted the lab and learned they did not have the urine specimen from November 2025, and he found a lab slip indicating the specimen required recollection and a new order if results were still needed. He also stated he was not sure whether the lab had notified him that the specimen was not collected and that there was no indication the facility had followed up with the lab regarding the urinalysis.
Failure to Obtain Ordered Urine Culture After Fall
Penalty
Summary
The facility failed to obtain a urine culture and sensitivity after a resident was found on the floor next to her bed. The resident had diagnoses including history of cardiac arrest, type 2 diabetes, neuropathy, hypertension, generalized anxiety, and muscle weakness. After the fall, the interdisciplinary team recommended labs including a CBC, BMP, urinalysis, and culture and sensitivity. The facility completed the STAT CBC, BMP, and urine testing, and the lab indicated a culture with results to follow, but the culture was not completed. During interview, the Regional Nurse Consultant stated the lab was unable to obtain a C&S and recommended collecting another urine sample, but this was not completed, and the resident was started on a prophylactic antibiotic to treat the urinary tract infection.
Failure to Obtain Physician-Ordered Laboratory Studies
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one resident. Clinical record review showed that a resident had an elevated potassium level, and the physician ordered a repeat Basic Metabolic Panel (BMP) to be done on a specific date. However, documentation revealed that the repeat BMP was not completed as ordered, and a subsequent order for a Comprehensive Metabolic Panel (CMP) was also not carried out. An interview with the Director of Nursing confirmed that staff did not obtain the required lab work on the dates specified by the medical practitioner. There was no evidence in the clinical records that the laboratory tests ordered by the physician were completed as required.
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