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:
Urine Culture and Sensitivity Not Obtained as Ordered: A resident with a suprapubic catheter, quadriplegia, and a history of UTI had cloudy, odorous urine and diaphoresis. Urology ordered the catheter changed and urine collected for C&S, but although the specimen was placed in the specimen refrigerator, no C&S results were received and the DON later verified the lab had no record of the specimen being picked up.
A resident with an indwelling catheter, nephrostomy tubes, and diagnoses including cystitis with hematuria and bladder cancer reported blood-tinged urine in a nephrostomy bag. An NP instructed staff to obtain a urine C&S, but the sample was not collected and no corresponding order appeared in the order recap. Later review showed only one urine test in the reviewed period, and the RN verified the ordered test was not completed.
Delayed Communication of Lab Results: A resident with DM, UTI, dysphagia, and impaired cognition had CBC and BMP results received by the facility in the evening, but the RN did not review and send them to the physician until the next morning. The DON confirmed the results should have been communicated promptly, and the facility policy required the attending physician to be notified as soon as test results were received.
Failure to Obtain Ordered BNP and TSH Labs: A resident with CHF, COPD, CAD, HTN, malnutrition, and moderate cognitive impairment had provider orders for a BNP to assess HF status and a TSH to monitor thyroid function while on Synthroid. When the ADON produced lab results, the BNP and TSH could not be found, and the ADON said she had even called the lab; the ordering provider later stated he did not remember the orders but suspected the BNP should have been completed if the other labs were done.
A resident with dysuria had urine testing ordered, and the lab later reported culture results showing the organism was resistant to Ciprofloxacin. Facility staff did not promptly notify the ordering practitioner of the culture result, and the resident continued receiving Ciprofloxacin before the MD was informed and changed the antibiotic to Keflex.
A resident receiving anticoagulant monitoring had an INR ordered as a repeat test after a subtherapeutic result, but the lab was not completed as ordered. Record review showed no INR report for the ordered draw, and an LPN confirmed the test was not done.
Urine Culture and Sensitivity Not Obtained as Ordered
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity test was obtained timely and as ordered for a resident with an indwelling suprapubic catheter. The resident had multiple diagnoses including quadriplegia, extended spectrum beta lactamase, neurogenic bowel, chronic respiratory failure, urinary tract infection, neuromuscular dysfunction of the bladder, chronic pain syndrome, diabetes, seizures, and hydronephrosis with ureteral stricture. A quarterly MDS assessment documented intact cognition and an indwelling catheter. On 05/19/26, the resident was noted to be diaphoretic with elevated blood pressure, and the catheter was draining cloudy, odorous urine. The catheter was flushed and continued draining, urology was contacted, and the nurse practitioner ordered a CBC and BMP. On 05/20/26, urology returned the call and ordered the suprapubic catheter changed in house, urine collected for culture, results faxed to urology, and minocycline started. The catheter was changed and the specimen was collected and placed in the specimen refrigerator, but the record contained no urine culture and sensitivity results from 05/20/26 through 05/29/26. The Corporate DON later verified the laboratory never received the specimen and had no record of the urine culture and sensitivity being picked up.
Failure to Obtain Ordered Urine Culture and Sensitivity
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity was obtained after an NP recommended it for a resident who reported blood-tinged urine in a nephrostomy bag. The resident had been admitted with diagnoses including heart failure, diabetes, acute cystitis with hematuria, acute kidney failure, and malignant neoplasm of the bladder, and nursing documentation noted she denied pain when she reported the blood-tinged urine. The NP was notified and instructed staff to obtain a urine sample for culture and sensitivity, but the record showed no urine culture was collected on that date and no order for the urine sample was present in the physician order recap. Record review showed the resident had impaired cognition, an indwelling catheter, and later care plans addressed alteration in elimination related to bilateral nephrostomy tubes and risk for urinary tract infection complications. Review of laboratory reports showed only one urine test during the reviewed period, collected later and resulting in growth of pseudomonas aeruginosa carbapenem resistant and klebsiella pneumoniae. During interview, the resident stated she had recently seen a urologist who capped the nephrostomy tubes and that she currently only had an ostomy; she denied current blood or pain. The RN verified the urine sample was not collected per the NP's recommendation and stated she was not sure why, and the facility policy stated staff would process test requisitions and arrange for tests.
Delayed Communication of Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results for one sampled resident were communicated to the physician in a timely manner. Resident 1 was admitted and later readmitted to the facility with diagnoses including type 2 DM, muscle weakness, need for assistance with personal care, dysphagia, UTI, history of falling, and depression. The resident’s H&P stated the resident had the capacity to understand and make decisions, while the MDS later indicated severely impaired cognition and dependence or assistance with several activities of daily living. A CBC and BMP were completed for Resident 1 and the laboratory report showed the results were sent to the facility at 9:41 p.m. RN 3 reviewed the results the next morning at 6:59 a.m. and confirmed during interview that he then sent the results to the resident’s physician. RN 3 stated he worked the 7 a.m. to 3 p.m. shift. The DON reviewed the same laboratory results and confirmed they were received by the facility on the evening they were sent, and stated the results should have been sent to the physician as soon as possible and should not have waited until the next day. The facility policy stated that when test results are provided to the facility, the attending physician shall be promptly notified and that the charge nurse receiving the results is responsible for notifying the physician.
Failure to Obtain Ordered BNP and TSH Labs
Penalty
Summary
The facility failed to obtain provider-ordered laboratory tests for one resident, including a BNP and a TSH level. The resident was admitted with a medical history that included acute on chronic congestive heart failure, COPD, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS assigned a BIMS score of 8, indicating moderate cognitive impairment. A history and physical note signed by the Medical Director ordered a BNP to assess the resident’s current heart failure status, along with CBC, CMP, and magnesium levels. A provider progress note later ordered a TSH level because the resident had a history of hyperthyroidism and was receiving Synthroid 50 mg daily. When the ADON provided lab results, the BNP and TSH could not be produced, and the ADON stated, "I even called the lab." The ordering provider later stated he did not remember the orders but suspected the BNP should have been done if the other labs were completed.
Delayed Notification of Urine Culture Results
Penalty
Summary
The facility failed to promptly notify the ordering physician or clinical practitioner of a laboratory result for one resident. The resident had been assessed by the attending physician for discomfort during urination, declined a genitourinary examination, and was ordered to have a urinalysis and urine culture obtained. Nursing staff collected the urine specimen and sent it to the lab, and the urinalysis results were forwarded to the facility and later reported to the attending physician, who then ordered Ciprofloxacin for cystitis. The urine culture results were forwarded to the facility and showed abnormal findings, including that Ciprofloxacin was resistant to the organism identified. A nursing progress note later documented that the attending physician was made aware of the urine culture results, and the physician discontinued Ciprofloxacin and started Keflex for a urinary tract infection. The resident received additional doses of Ciprofloxacin after the facility had already been notified by the lab that the organism was resistant to that antibiotic.
Missed INR Lab Order for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one resident who was being monitored for anticoagulant therapy. Resident #5 had a physician order for an INR to be drawn on 4/27/26, but review of the medical record showed no INR laboratory report for that date. An After-Hours Telehealth Consult note dated 4/26/26 documented that the resident’s INR was subtherapeutic based on lab results from 4/26/26, and the provider ordered a repeat INR for 4/27/26. During interview on 4/29/26, an LPN confirmed that the INR was not completed as ordered.
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