Failure to Maintain Complete Laboratory Records in Resident Files
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including acute respiratory failure with hypoxia, Crohn's disease, and hemiplegia, multiple physician orders for laboratory tests such as Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Clostridioides difficile (C-diff) were documented, but the corresponding laboratory results were not found in the resident's medical record. Nursing progress notes and physician orders confirmed that these labs were ordered and should have been completed, yet no results were available in the record during the review period. For another resident with schizoaffective disorder, diabetes mellitus with kidney complication, and chronic kidney disease, an active physician's order for Glycated Hemoglobin (HgbA1C) to be drawn every six months was present, but no laboratory results were located in the medical record. Interviews with staff revealed that STAT lab results were typically faxed and reviewed by the provider, while routine labs were accessed through an online portal and were supposed to be uploaded to the resident's medical record by medical records staff. However, issues with the online portal and differences in how STAT and routine labs were managed led to missing documentation of lab results in the residents' records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Lab Results in Medical Records: The facility failed to keep lab reports accurately maintained and readily available in the medical record for two residents. One resident had ordered anemia-related labs, including ferritin, serum iron, transferrin, and TIBC, that were not found in the chart, and another resident had a TSH order with reflux to free T4 where the T4 was present but the TSH result was missing. The DON stated some results had to be manually printed from an external portal and scanned into the record, and that the missing TSH should have been in the chart.
Missing Lab Results in Resident Records: The facility did not keep complete lab records in the clinical charts for two residents. One resident with schizophrenia, OCD, dementia, and adult failure to thrive had ordered CBC, CMP, TSH, Depakote, ammonia, B12, and UA results that could not be located in the chart, while another resident with AFib, DM, anxiety, and bacteremia had ordered weekly CBC w/diff, CMP, CRP, and CK results missing from the record. RN and DON interviews confirmed the lab values were available on the portal or had been faxed, but were not filed in the residents' medical records.
A resident on transmission-based precautions had a physician-ordered urinalysis culture and sensitivity collected by a contracted lab, but the test results were not filed in the clinical record as required by facility policy. During record review, surveyors found no lab report in the chart, and the ADON/IP later produced a copy of the results and acknowledged they had not yet been filed. These findings were discussed with facility leadership during the exit conference.
Missing Laboratory Results in Resident Records: Survey review found that lab reports were not filed in the charts for multiple residents. Missing documentation included urine culture results, CBC, BMP, VIT D, CMP, ESR, and CRP results, and one CBC was later found to have been cancelled because the sample was clotted. Staff, including the DON and Corporate QA Nurse, were unable to locate the results in the medical records and obtained some reports directly from the lab website or lab after the surveyor requested them.
Missing Lab Results in Resident Record: A resident with chronic respiratory failure with hypoxia had ordered BMP, ABG, and Vitamin D labs marked completed, but the corresponding results were not found in the chart. Staff described a fax-to-chart process involving nursing review, physician review, and medical records scanning, yet the lab reports were still missing from the resident's medical record.
The facility failed to maintain accurate records and reconciliation of controlled substances for two residents, resulting in medication discrepancies and diversion by an LPN. In both cases, oxycodone was signed out and administered without proper documentation or resident request, and required dual signatures for narcotic counts were missing across multiple shifts.
Missing Lab Results in Medical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were accurately maintained and readily available in the medical record for 2 of 32 sampled residents. For Resident 3, who was admitted and later readmitted with diagnoses including hypo-osmolality, hyponatremia, and anxiety, a physician order dated 12/28/25 required additional labs for 12/29/25, including ferritin level, serum iron, transferrin, and TIBC for anemia. Those laboratory tests dated 12/29/25 were not located in Resident 3's medical record during review from 3/16/26 through 3/19/26. For Resident 4, who was admitted with diagnoses including vascular dementia, depression, PTSD, constipation, and prediabetes, a physician order dated 1/26/26 revealed a TSH with reflux to free T4. The record showed the T4 was completed on 1/26/26, but there were no TSH results in the medical record. During interview on 3/19/26, the DON stated the TSH had been completed but was not in the record and needed to be manually printed from an external portal and scanned into the medical record; the DON stated the TSH results should have been in the medical record.
Missing Lab Results in Resident Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the residents' clinical records for 2 of 24 sampled residents, identified as Residents 25 and 43. Resident 25 was admitted and later readmitted with diagnoses including schizophrenia, obsessive-compulsive disorder, dementia, and adult failure to thrive. A physician order dated 6/18/25 required CBC, CMP, Depakote, and TSH every 6 months, and another order dated 11/25/25 required CBC, CMP, TSH with reflex T4, ammonia, B12, and UA with micro and reflex to culture, with instructions to obtain a urine sample and draw labs the next day. The lab results for both orders could not be located in the resident's medical record. Resident 43 was admitted with diagnoses including atrial fibrillation, diabetes mellitus, generalized anxiety disorder, and bacteremia. A physician order dated 12/10/25 required CBC with differential, CMP, CRP, and CK every Wednesday. No results from 12/24/25 were found in the medical record. During interview, RN 1 printed the missing lab values from the online portal and stated they had not been signed by the physician and filed in the record. The DON stated lab results were faxed to the facility and also available on the online portal, and that after physician signature they were filed in the residents' medical records, but she was unable to find the 12/24/25 lab draw for Resident 43.
Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
Missing Laboratory Results in Resident Records
Penalty
Summary
Complete, dated laboratory records were not maintained in the residents' clinical records for 5 of 25 sampled residents. Survey review found missing urine culture and blood laboratory results for multiple residents, and one resident's clotted sample result was not located in the medical record. The missing records involved residents 3, 7, 8, 33, and 56, and the facility staff were unable to locate the expected laboratory documentation during the survey review. Resident 56 had diagnoses including fracture of the left femur, fracture of the right femur, repeated falls, and overactive bladder. After an infection prevention/control note documented a urine dip and physician notification for possible UTI, with an order for Septra and urine C&S, the urine culture results could not be found in the resident's medical record. The DON stated she was unable to locate the urine culture results and said Medical Records uploaded records to resident charts, with results expected within one business day. Resident 3 had diagnoses including hypo-osmolality and hyponatremia and chronic kidney disease with heart failure. A physician ordered UA with C&S for possible UTI, and the record later showed the lab reported mixed flora, probably contamination, with the C&S not completed; however, the laboratory results were not in the resident's record until the surveyor requested them. Resident 33 had diagnoses including myopathy, sepsis, pneumonitis due to inhalation of food and vomit, and Alzheimer's disease; a CBC and CMP were ordered, the CMP was present, but the CBC was missing from the record and later obtained from the lab as a cancelled clotted sample. Resident 7 had diagnoses including attention to colostomy, atrial fibrillation, schizophrenia, epilepsy, and neuromuscular dysfunction of bladder; CBC, BMP, and VIT D results collected for the ordered labs could not be located in the record. Resident 8 had diagnoses including cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia; CBC, CMP, ESR, and CRP results ordered for the resident could not be located in the medical record, and the DON stated the facility would call the lab if results were not received.
Missing Lab Results in Resident Record
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's clinical record for Resident 25, who was admitted with diagnoses including chronic respiratory failure with hypoxia. Review of the record showed physician orders for a BMP, an ABG, and Vitamin D that were marked completed, but the corresponding lab results could not be located in the resident's medical record. The missing results included the 4/17/25 BMP, the 4/17/25 ABG ordered for pulmonary clearance for surgery, and the 5/6/25 Vitamin D lab result. During interviews, staff described a process in which lab results were faxed to the facility, reviewed by nursing leadership and the physician, then placed in a medical records folder for scanning into the resident's chart. The Unit Secretary, Executive Assistance, Medical Records Lead, and DON each described this workflow and stated that the results should have been uploaded to the medical record within about a week. Despite this process, the three lab reports for Resident 25 were not found in the medical record, and the ES confirmed that the ABG was located in the respiratory therapy area while the BMP and Vitamin D results were still being sought.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.
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