F0684

J

Failure to Obtain Ordered Labs and Monitor Decline Leading to Acute Renal Failure

Grayville, Illinois Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders, obtain and act on ordered laboratory tests, and adequately assess and monitor a cognitively intact resident with multiple serious comorbidities, including acute on chronic heart failure, COPD, acute kidney failure, CKD stage IIIa, and insulin‑dependent type 2 diabetes. The resident was admitted with dysphagia, poor intake, and an indwelling catheter, and the MDS documented substantial/maximal assistance for toileting and use of an indwelling catheter. The care plan included psycho‑social and delirium focus areas, with an intervention to report abnormal lab results to the MD, and a nutritional problem related to dysphagia with instructions to monitor and record intake every meal; however, there were no care plan focus areas for diabetes mellitus or the indwelling catheter. On 12/28, nursing documentation showed the resident was not taking food or thickened liquids, was non‑verbal, and had a firm bladder; a Foley catheter was inserted with 450 ml of clear yellow urine obtained, and the MD was notified.

Later on 12/28, the MD ordered Megace, CBC, CMP, TSH, UA and urine culture, protein supplements, and nutrition and psychiatry consults. The order summary reflected one‑time orders for CBC, CMP, TSH, and UA with culture starting 12/29, as well as an order for morning accuchecks for diabetes and, later, an order to record catheter output every shift starting 01/07. The DON later stated the CBC, CMP, and TSH were never completed because the nurse entered them on the wrong flowsheet so they did not populate to the EMAR, and the facility did not discover this until after the incident. The DON also acknowledged that the UA was completed but the results, which ultimately showed >100,000 CFU/mL Pseudomonas fluorescens and >100,000 CFU/mL Enterococcus faecalis, were not available in the chart until they were printed weeks later; the Administrator stated the lab was supposed to deliver results and that nurses should have followed up. Staff interviews showed that, despite the presence of an indwelling catheter and poor intake, the facility’s practice was not to monitor intake or output unless there was a specific physician order, and the Administrator and DON confirmed they did not routinely monitor outputs with a catheter unless ordered.

From 01/07 through 01/11, the treatment record documented catheter outputs that nephrology later characterized as not good outputs and potential indicators of renal problems or poor intake, with several shifts showing low volumes and some shifts with no output recorded. CNAs and nurses reported the resident was not drinking well, was a poor eater, had very little urine in the catheter bag, complained of needing to urinate, and had shortness of breath at times. The MAR showed ordered morning accuchecks for diabetes, but there were no documented blood glucose checks on several days, including 01/11. On 01/11, the family member, using a continuous glucose monitor, reported blood sugars in the 60s throughout the day and found the resident shaking and struggling to breathe. The Assistant DON gave the family member a tube of instant glucose to administer, did not check the resident’s blood sugar at that time, and later stated she did not know why she allowed the family member to give it. The family member reported the nurse “threw” the glucose and spoon at her without instructions and did not enter the room until after 911 was called. EMS documented that the nurse said she had not called 911 and saw no reason to send the resident out, that the nurse refused to assist EMS in the room, that the resident’s SpO2 was 89% and improved with 3 L O2, and that the catheter drainage was cloudy with specks of blood and minimal output. The resident was transported to the hospital, where he was diagnosed with acute renal failure and hyperkalemia requiring emergent dialysis, and was later transferred to another hospital for higher‑level nephrology care and ultimately to hospice, where he died. The surveyors determined that the facility failed to obtain ordered labs, failed to follow up on UA and culture results, and failed to notify the physician of the resident’s decline, resulting in delayed medical treatment and constituting Immediate Jeopardy beginning 12/28.