Failure to Communicate Critical Lab Result Leads to Resident Death
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to obtain ordered TSH monitoring for a resident receiving levothyroxine. A physician ordered repeat TSH testing for low thyroid hormone, but the lab was not completed and the resident continued on therapy without the ordered monitoring. The consultant pharmacist later recommended a TSH recheck, yet the record showed no documentation that the lab had been obtained. The ADON, DON, and physician all stated the TSH order should have been placed or completed.
A resident with an abdominal wound, ileostomy, and history of sepsis had a wound culture that grew E. coli, but the result was not promptly reported to the ordering practitioner. Staff documented the culture result, discussed the resident’s pain and redness, and noted the resident asked about antibiotics, yet the NP was not notified until several days after the lab finalized. Interviews with the wound care nurse, LPN, NP, DON, ADON, and Administrator confirmed the delay in communication and treatment.
Failure to Collect Ordered Urine Toxicology Specimen: A resident with anxiety disorder, opioid dependence, and COPD had an acute change in condition with ALOC, pinpoint pupils, and later lethargy, hallucinations, jerking movements, and bowel loss, requiring Narcan and transfer for further evaluation. After readmission, a urine toxicology test was ordered, but the specimen was collected in the wrong container and could not be completed; staff also failed to communicate the need to recollect the sample and the resident's refusal to the oncoming shift.
A resident with CKD, hydronephrosis, kidney cyst, and dementia had a positive urine culture and sensitivity reported to the facility, but the result was not promptly communicated to the attending MD. Staff interviews and record review showed the LPN/RN did not notify the MD until the next morning, and IV abx for the UTI were not started until later, after the abnormal lab was finally addressed.
Failure to Notify Physician of Abnormal Lab Results: A resident with hyperkalemia and CKD stage 4 had abnormal BMP/CMP results showing elevated K+, BUN, creatinine, and low CO2, calcium, and GFR. The record did not show that the MD was notified of the abnormal lab results, and staff gave inconsistent accounts of who handled lab notifications.
A resident with alcohol dependence, stroke history, toxic encephalopathy, vascular dementia, and anxiety had Depakote, CMP, and CBC labs ordered before a psychotropic medication increase, but the facility did not obtain the labs as ordered. The behavioral health NP said the labs were to be drawn on the next lab day, while the DON confirmed the resident had not had labs drawn since the behavior meeting, the orders were not entered in time, and the provider was not notified that the labs were missed.
Failure to Obtain Ordered TSH Monitoring
Penalty
Summary
The facility failed to ensure physician-ordered laboratory services were provided for Resident #13, who was receiving levothyroxine for low thyroid hormone. A physician order dated 06/26/2025 directed that TSH be repeated in three weeks, but review of the medical record showed the ordered TSH laboratory test was not obtained. The resident continued levothyroxine therapy without the ordered thyroid monitoring, and review of the consultant pharmacist’s monthly medication regimen review dated April 2026 recommended a TSH recheck in six months to one year, with no documentation that the laboratory monitoring had been completed. Physician progress notes from January 2026 through July 2026 did not show that the original TSH order had been discontinued or modified. During interviews, the ADON stated the resident’s last TSH was obtained in 2024 and was unsure why follow-up testing had not been completed, the DON stated she would have expected the TSH order to have been entered, and Physician #1 stated the TSH order should have been placed.
Delayed Reporting of Positive Wound Culture
Penalty
Summary
The facility failed to ensure that abnormal lab results were promptly reported to the ordering practitioner for one resident. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery, diverticulitis, sepsis, and an open abdominal wound. Her care plan identified risk for skin breakdown related to a new ileostomy, indwelling catheter, and impaired mobility, with instructions to observe for signs of infection or delayed healing and report them to the physician as needed. The resident was cognitively intact with a BIMS score of 15. On 6/22/26, the wound care nurse observed excessive drainage from the abdominal wound during dressing care, noted the ileostomy site was soiled, and notified the MD, who ordered a wound culture. The specimen was collected on 6/22/26, received by the lab on 6/23/26, and resulted positive for Escherichia coli on 6/25/26 at 12:14 p.m. Nursing documentation showed the resident later complained of pain and redness at the site, and on 6/27/26 the resident asked about antibiotics and was told the culture result was being reviewed and that the upcoming nurse should message the MD in the morning. The positive culture was not communicated to the NP until 6/28/26, when the wound culture result was reviewed and new orders were obtained for a midline/PICC and ertapenem. The resident stated she believed she was already receiving antibiotics and said she was told the culture was positive and placed in the file without follow-up to the doctor. Staff interviews confirmed the delay: the wound care nurse said she assumed the resident knew about antibiotics, the LPN said she did not know the culture was pending, the NP said she was first notified on 6/28/26 and should have been notified right away or the next morning, and the DON, ADON, and Administrator all confirmed the delay in reporting and treatment.
Failure to Collect Ordered Urine Toxicology Specimen
Penalty
Summary
The facility failed to ensure a urine specimen ordered for a urine toxicology test was collected for one resident after a change in condition and transfer to the GACH. The resident had diagnoses including anxiety disorder, opioid dependence, and COPD. After being found with altered level of consciousness, pinpoint pupils, and only responding to painful stimuli, the resident was given Narcan and became alert and verbally responsive. Later that evening, the resident was observed lethargic with visual hallucinations, jerking movements, and loss of bowels, and was transferred by paramedics for further evaluation and treatment. Upon readmission, CBC, CMP, UA, and a urine toxicology test were ordered. The urine toxicology specimen could not be completed because it was collected using the wrong media, and the specimen needed to be recollected with a new order obtained. During interviews, an LVN stated she received report that the urine sample needed to be recollected but did not endorse that information to the oncoming shift. An RNS stated he saw that the urine toxicology screen had not been completed because the specimen was collected in the wrong container, and that the resident refused to give a urine sample during the shift, but he did not pass that information on because he got busy and forgot. The DON stated the refusal should have been endorsed to the next shift so nurses could have attempted to collect the specimen.
Delayed notification of abnormal urine culture and sensitivity results
Penalty
Summary
The facility failed to notify Physician 1 of Resident 90’s final urine culture and sensitivity result when it was reported to the facility at 10:27 PM on 6/13/2026. Resident 90 was admitted with chronic kidney disease, an acquired kidney cyst, hydronephrosis with renal and ureteral calculous obstruction, and dementia, and her history and physical indicated she did not have the capacity to understand and make decisions. Her care plan identified her as at risk for fluid retention and recurrent UTI, with interventions to monitor for signs and symptoms of UTI and to follow up with laboratory results such as urinalysis and urine culture and sensitivity as ordered. Resident 90’s lab record showed that the urine culture grew Proteus mirabilis and that the final urine culture and sensitivity was reported to the facility on 6/13/2026 at 10:27 PM. During interviews, LVN 3 stated she did not know about the positive UA or urine culture until the morning of 6/15/2026 when RN 1 notified her. RN 1 stated she found the abnormal laboratory results first thing in the morning on 6/15/2026 and then notified Physician 1, and stated it was the responsibility of the licensed nurse to review lab results and notify the physician of abnormal or critical results promptly. The Infection Preventionist Nurse stated there was no documented evidence in the nursing progress notes that the final urine culture and sensitivity results were reported to Physician 1 on 6/13/2026 or 6/14/2026, and stated the licensed nurse who received the results did not notify Physician 1. The IPN also stated that if the licensed nurse was unable to notify Physician 1 promptly, the Medical Director should have been notified. Resident 90 did not start IV antibiotic treatment until the morning of 6/15/2026. The DON stated that when the facility receives abnormal or critical abnormal lab results, it is the responsibility of the licensed nurse to notify the physician promptly to prevent a delay in treatment.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility did not ensure a resident’s physician was promptly notified of laboratory results that were outside clinical reference ranges. The resident had diagnoses of hyperkalemia and chronic kidney disease stage 4, and a physician order dated 3/3/26 directed BMP testing every 2 weeks related to hypokalemia and sodium levels. A nursing note dated 4/8/26 documented a potassium level of 6.2, that the MD was spoken with, and that a new order for Kayexalate was obtained with a repeat BMP ordered for 4/10/26. On survey review, the resident’s 4/9/26 CMP showed multiple abnormal values, including potassium 5.3, chloride 120, carbon dioxide 14, BUN 67, creatinine 5.34, GFR 11, and calcium 7.2, and the 4/21/26 CMP also showed abnormal values, including potassium 5.8, chloride 121, carbon dioxide 13, BUN 60, creatinine 5.47, GFR 10, and calcium 7.5. The surveyor was unable to locate documentation that the physician was notified of either set of abnormal results. During interviews, staff gave differing descriptions of who was responsible for lab notification, and UM-D stated there was nothing charted regarding the abnormal labs on 4/9/26 and 4/21/26.
Ordered Labs Not Obtained for Resident on Psychotropic Medication
Penalty
Summary
The facility did not ensure laboratory services were obtained as ordered for one resident who was admitted with diagnoses including alcohol dependence, history of stroke, toxic encephalopathy, vascular dementia, and adjustment disorder with anxiety. The resident was being followed by a behavioral health NP and had a quarterly psychotropic review on 6/9/26 documenting Depakote and olanzapine for paranoid and aggressive behaviors, with a Depakote lab ordered for levels before increasing medication. Survey review did not find documentation of the behavior meeting or orders for labs to be drawn in the resident’s record. During interviews, the behavioral health NP stated that labs were ordered to be drawn before increasing the resident’s medications and that they were to be drawn on the facility’s next lab day. The DON stated the facility’s lab draws occur on Mondays and Thursdays, but after calling the lab with the surveyor present, confirmed the resident had not had any labs drawn since the behavior meeting. Written communication from the facility/provider app showed a request for Depakote, CMP, and CBC levels and a note to add them to the 6/11 lab day, but the DON later stated the orders were not entered prior to 6/16/26, the labs were not obtained as ordered, and the provider was not made aware that the labs had not been obtained.
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