F0770

D

Failure to Obtain Ordered Laboratory Tests for Two Residents

Elkton, Maryland Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Facility staff failed to obtain ordered laboratory tests for two residents as identified during a complaint survey. For one resident admitted in January 2026 with diagnoses including diabetes and anemia, physician orders dated 1/5/26 directed that a CBC, CMP, and magnesium level be completed on 1/6/26. Review of the medical record on 1/29/26 showed no laboratory results for that date and no nursing documentation explaining why the ordered labs were not completed. In an interview on 1/29/26 at 1:45 PM, the Director of Nursing confirmed that staff did not obtain the physician-ordered laboratory tests for this resident.

For another resident admitted with a diagnosis including pneumonia, the medical record showed that a Physician Assistant evaluated the resident on 1/7/26 for abnormal laboratory results and documented an order to repeat a CBC in the morning. A nurse’s note later that night stated that labs from 1/7/26 were reviewed by the Physician Assistant and that the resident already had an order for a CBC in the morning. However, review of the laboratory results revealed that no labs were drawn on 1/8/26. This resident was discharged on 1/13/26 without the repeat CBC having been completed. In an interview on 1/29/26 at 10:28 AM, the Director of Nursing confirmed that the ordered CBC was not obtained for this resident.