F0770

D

Delayed Lab Draws and Results for Stool, STAT Infection Workups, and PT/INR Monitoring

Stockton, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely laboratory services and results for four residents after physician orders were obtained. For one resident with chronic kidney disease, Parkinson’s disease, and dementia, a change in condition was documented when loose, mucus-like stool with odor was noted. A stool sample for C. difficile testing was ordered and picked up by the contracted lab, but the result was not returned within the expected timeframe. Nursing notes show repeated calls to the lab with no answer, eventual notification that the specimen was no longer viable, and a lack of prior notification to the facility about this issue. A subsequent STAT C. difficile order was placed, the specimen was picked up, and staff again made multiple calls to the lab before the result was finally received, creating a prolonged delay between the initial change in condition and receipt of the test result.

Another resident with type 2 diabetes and benign prostatic hyperplasia experienced a change in condition with complaints of not feeling well, dark urine, and hematuria. The physician ordered STAT CBC, BMP, and UA with C&S, and also ordered staff to follow up with the lab if the blood draw was not completed or to call for STAT results. Progress notes document that staff called the lab, faxed the STAT order, and that no one came initially to draw the blood. The urine sample was not collected and picked up until the following day, and by several days later the UA C&S results were still pending. The physician, finding no lab results available during assessment, ordered the resident to be sent to the ED, where a UTI was diagnosed and antibiotic therapy initiated.

A third resident with spastic quadriplegic cerebral palsy and communication disorders was on warfarin and required regular PT/INR monitoring. Orders and progress notes show multiple scheduled and STAT PT/INR tests in December, but there were gaps in documentation of draws, delays in obtaining results, and repeated unsuccessful attempts to contact the lab. Staff documented that PT/INR was drawn but results were still “awaiting,” that phlebotomists came at night to draw STAT labs, that calls to the lab went unanswered or the phone line cut out, and that additional STAT PT/INR orders had to be placed due to missing or delayed results. Nurses and the DON reported that since switching to a new lab company, results were faxed rather than integrated into the electronic chart and were taking longer, with no backup lab available other than sending residents to the ED.

A fourth resident with atrial fibrillation and congestive heart failure, also on warfarin, had weekly PT/INR testing and dosing managed through a coumadin clinic. Progress notes show a change in condition related to missed warfarin doses and a STAT PT/INR ordered and called to the lab. A phlebotomist drew the STAT PT/INR in the early morning, but nurses documented multiple follow-up calls to the lab without results, confusion over requisitions that did not include PT/INR, and the need to create a new requisition and redraw blood. Hospital anticoagulation communication records later reflected missed warfarin doses on several days, which the DON attributed to the lab’s failure to complete the PT/INR draw and the resulting lack of current dosing orders. Throughout these events, the DON and Administrator confirmed that the lab was expected, per contract and facility practice, to prioritize STAT orders and return results promptly, but that there were repeated delays in draws and reporting for these four residents.

The facility’s own policy stated that the lab or testing source would report test results to the facility and that concerns about handling or reporting of results should be communicated to the DON or Medical Director, without delaying clinically appropriate management. Interviews with multiple nurses and the DON confirmed that staff repeatedly attempted to follow up with the lab by phone and fax, that results were not received within the expected 4–8 hours for STAT draws and 24–72 hours for routine tests, and that there was no alternative contracted lab at the time. The contracted lab’s representative described a process in which orders are received by email or fax, confirmed with the facility, and prioritized for STAT processing, but the documented experiences for these four residents show that orders, draws, and results were not consistently handled within those expectations, leading to the cited deficiency in timely laboratory services and test results.