F0658

D

Failure to Follow Lab Orders and Report Abnormal Kidney Function Results

Petaluma, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of care and physician orders for a resident with a history of chronic kidney disease and a displaced bimalleolar fracture of the right lower leg. The resident was admitted in December 2025, and her MDS showed a BIMS score of 12, indicating moderately impaired cognition. A physician’s order dated 12/10/25 directed that CBC and BMP labs be obtained weekly on Wednesday mornings for four weeks. The December 2025 eMAR showed the CBC and BMP as completed on 12/17/25 and 12/31/25, but the EMR contained no evidence that the 12/17/25 labs were actually collected. The DON confirmed the order and the eMAR entries, but could not provide documentation that the 12/17/25 labs were obtained or that results were communicated to the physician.

On 12/31/25 at 7:05 a.m., CBC and BMP labs were collected, and the results were reported to the facility on 1/02/26 at 11:51 a.m. The lab report was flagged and showed abnormal values, including an elevated WBC of 14.2 K/mm3, BUN of 42 mg/dL, creatinine of 1.34 mg/dL, and BUN/CREAT ratio of 31, all marked as high. Despite these abnormal and flagged results, the EMR contained no evidence that an SBAR was initiated on 1/02/26 or that the physician was contacted regarding these lab findings. The DON confirmed that these abnormal values should have been reported to the physician and included in an SBAR so the physician could implement interventions, and stated that if an elevated BUN is left untreated, it can cause kidney injury.

Subsequent documentation showed that on 1/03/26 at 5 p.m., an SBAR was completed for increased edema to the resident’s bilateral lower extremities, and on 1/04/26 at 9 p.m., another SBAR documented decreased urine output, lower abdominal pain or tenderness, difficulty voiding, and a bladder scan showing approximately 1 liter of retained urine. On 1/07/26 at 11:31 a.m., a nurse’s note recorded the resident’s complaint of back pain rated 10/10 and that the resident was in distress, with an MD order for transfer to the ER for further evaluation. In the ED on 1/08/26, the resident’s BUN was 102 mg/dL and creatinine 1.67 mg/dL, and she was diagnosed with back pain, UTI, AKI, and dehydration. Facility policies required prompt physician notification of diagnostic test results, documentation of changes in condition, and that RNs and LPNs obtain ordered lab tests and notify the physician of changes in condition. Interviews with nursing staff and the DON confirmed that abnormal lab values were expected to be reported to the physician and documented, and that SBARs should be completed for out-of-range labs, which did not occur for the abnormal results reported on 1/02/26.