Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
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