Failure to Notify Provider of Critical Lab Results Due to Missed Communication
Summary
The facility failed to promptly notify the ordering provider of critical laboratory results for a resident with multiple serious medical conditions, including severe chronic kidney disease, diabetes, and a history of heart surgery. On two separate occasions, critical lab results were reported by the laboratory, which attempted multiple times to contact the facility during early morning hours. Facility staff did not answer the phone during these attempts, and there was no documentation that staff returned the lab's calls or communicated the critical results to the provider. Additionally, the nurse coming on shift was not informed about the lab draws or the critical results during shift change, and only became aware of the situation when the resident's wife brought it to her attention. The Director of Nursing confirmed that the facility had ongoing issues with staff being unreachable by phone and lacked a message system for callers. The expectation was for staff to communicate critical lab results to the provider as soon as possible, but this did not occur in these instances.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
