Failure to Maintain Accurate Controlled Substance Records and Reconciliation
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.
Penalty
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Laboratory and imaging results were not filed in a resident's chart after an NP evaluated the resident for SOB and ordered a chest x-ray and labs for possible fluid retention. The resident had HF and DM, and staff stated the results were available in an outside EHR, so they did not routinely place them in the resident's record or document the provider's response.
A resident with hyperkalemia had abnormal lab results available at the facility, but they were not uploaded into the EMR in time for provider review. An on-call NP relied on an older normal potassium result and gave an order to hold a potassium-lowering med, while another NP later documented elevated potassium and ordered continued treatment. Staff could not locate the more recent lab reports in the chart, and the DON confirmed the facility’s lab retrieval and scanning process left the results out of the resident’s record.
Missing laboratory reports were found in the clinical records for three residents. One resident with renal dialysis, diabetes, and anemia in CKD had ordered CBC and other admit labs with no results located; another resident with kidney failure, thrombocytopenia, and CMML had ordered CBC, BMP, CMP, and other labs with no results located; and a third resident with cirrhosis, hepatic failure, anxiety, depression, and chronic pain had multiple ordered LFP, BMP, CBC, INR/PT, prealbumin, and UA/C&S results missing from the chart. The RNC stated the lab results had to be obtained from the hospital or portal and were not in the residents’ records.
Complete, dated lab records were not maintained in the clinical records for two residents. One resident with ESRD, renal dialysis dependence, kidney transplant rejection, pulmonary HTN, CHF, and HTN had ordered lipid panel and A1c results missing from the chart. Another resident with hemiplegia, cerebral infarction, morbid obesity, DM2, and foot injuries had ordered CMP, BMP, and A1c results absent from the record, and the DON stated the results had been requested from the lab.
Missing Monthly CBC Results in Resident Record: A resident with schizophrenia, CHF, and an intracranial injury had active physician orders for monthly CBCs related to clozaril use, but multiple monthly CBC results were not filed in the EMR. During interview, the RDCS stated lab results should be uploaded under the Documents or Results tab, and if they were not there, the facility likely did not have a record that the labs were completed.
Missing Urinalysis Result in Resident Record: A resident with severe cognitive impairment, an indwelling urinary catheter, and chronic UTIs had a urinalysis ordered for behavioral and cognitive changes. The specimen was collected, but the result was not found in the chart, and the DON confirmed there was no indication it had been tested at the lab or that the facility had attempted to obtain or follow up on the result.
Laboratory and Imaging Results Not Filed in Resident Record
Penalty
Summary
The facility failed to ensure laboratory reports were filed in the resident's clinical record for 1 of 1 resident reviewed for edema monitoring. The resident had diagnoses of heart failure and diabetes, and the quarterly MDS identified moderate cognitive impairment, no behaviors, no rejection of cares, and partial/moderate assistance needed for transfer. A progress note documented the resident's concern that her lungs were filling up with fluid again and her request to see a doctor. The nurse practitioner evaluated the resident for shortness of breath and ordered a chest radiograph to assess for pulmonary fluid retention along with laboratory studies. Review of the electronic health record did not identify the chest imaging or laboratory results, and there was no documentation of the provider's response to those results. During interview, the RN stated the chest x-ray and laboratory testing had been completed, but the results were not placed in the resident's EHR because they were available in the outside facility's EHR, and staff relied on the outside clinic to ensure the facility received them. The regional RN stated the facility should ensure all laboratory results are followed up on and a copy is placed in the resident's EHR.
Missing Abnormal Lab Results in Resident Record
Penalty
Summary
The facility failed to ensure abnormal laboratory results were uploaded into a resident’s electronic medical record in a timely manner. Resident #48, a frail and elderly resident admitted in January 2026 with multiple medical conditions including pressure ulcer and hyperkalemia, had two nurse practitioner progress notes on 7/08/26 that conflicted regarding treatment for elevated potassium. One on-call NP note documented review of a potassium result from 6/29/26 that was normal and gave an order to hold sodium polystyrene sulfonate because the medication was not available from the pharmacy, while another NP note documented that the resident had high potassium levels on 7/06/26 and 7/08/26 and ordered continuation of sodium polystyrene sulfonate and another medication used to treat high potassium. A review of the miscellaneous scanned documents showed the most recent lab result in the record was from 6/29/26, and the lab reports for 7/06/26 and 7/08/26 were not in the resident’s chart when reviewed. During interviews, staff searched for the missing lab reports but could not locate them in the record. The DON explained that the hospital did not automatically transmit lab results and that only the ADON had access to retrieve them from the hospital portal, after which they were printed, reviewed, and then scanned into the resident’s medical record by the receptionist. Staff acknowledged that the abnormal lab results were available at the facility but were not placed in the resident’s record when the on-call provider reviewed the chart, and they could not explain why the most recent lab results were missing.
Missing Laboratory Reports in Resident Records
Penalty
Summary
Complete, dated laboratory records were not kept in residents’ clinical records for 3 of 40 sampled residents. For Resident 4, who was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease, physician orders included admit labs and repeat CBCs on multiple dates, but no laboratory results could be located in the medical record. For Resident 99, who was admitted and later readmitted with diagnoses including unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia, physician orders included admit labs, a CBC and BMP, and later CBC and CMP orders, but no laboratory results could be located in the medical record. For Resident 46, who was admitted with diagnoses including fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome, multiple orders were written for LFPs, BMPs, CBC, INR/PT, prealbumin, and urinalysis with culture and sensitivity, but the laboratory results for all listed orders were not located in the medical record. The Regional Nurse Consultant stated that the lab results had to be obtained from the hospital or printed from the laboratory portal and were not contained in the residents’ medical records.
Failure to File Ordered Laboratory Results in Resident Records
Penalty
Summary
Complete, dated laboratory records were not kept in the residents' clinical records for 2 of 36 sampled residents. Resident 6 was admitted and later re-admitted with diagnoses including kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension. On 3/9/26, a physician ordered a lipid panel and hemoglobin A1c, but no laboratory results for those tests could be found in the resident's medical record. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of the right toe, and a non-pressure injury of the left foot. The resident had physician orders for a CMP on 10/22/25 and 10/29/25, and for a BMP and hemoglobin A1c on 11/12/25, but no documentation of the ordered laboratory results was found in the medical record. During interview, the DON stated that the lab results were requested from the laboratory and that the results would be uploaded into the residents' records.
Missing Monthly CBC Results in Resident Record
Penalty
Summary
Keep complete, dated laboratory records in the resident's record was not met for 1 of 19 sampled residents when the facility did not ensure that ordered CBC laboratory results were filed in the resident's clinical record. Resident 12 was admitted and later readmitted with diagnoses including schizophrenia, chronic diastolic congestive heart failure, and unspecified intracranial injury. The resident had physician orders for monthly CBCs related to clozaril use, first dated 9/29/25 and later continued on 3/6/26, but the medical record reviewed from 6/1/26 through 6/4/26 did not contain monthly CBC results for June 2025, July 2025, August 2025, February 2026, April 2026, and May 2026. During interview, the Regional Director of Clinical Services stated that lab results should be uploaded under the Documents tab or Results tab in the electronic medical record, and if they were not found there, it was likely the facility did not have a record that the labs were completed.
Missing Urinalysis Result in Resident Record
Penalty
Summary
Laboratory reports were not kept in the resident's medical record for one resident with severe cognitive impairment and multiple diagnoses including bladder obstruction, renal insufficiency, heart failure, diabetes mellitus, non-Alzheimer's dementia, and a history of cerebrovascular accident. The resident had an indwelling urinary catheter and chronic UTIs, and a physician order dated 3/17/26 directed a urinalysis after behavioral and cognitive changes and due to the history of chronic UTIs. A urinalysis was collected on 3/19/26, but there was no evidence in the medical record that the facility received the result or followed up on it. The DON confirmed on 5/21/26 that the urinalysis result was not in the chart, there was no indication it had been tested at the laboratory, and the facility had not attempted to obtain or follow up on the result.
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