Failure to Complete Ordered Laboratory Tests and STAT Urinalysis
Penalty
Summary
The deficiency involves the facility’s failure to obtain and process physician‑ordered laboratory tests, including a STAT urinalysis, for a resident with multiple chronic conditions. The resident had diagnoses including COPD, type 2 diabetes, atrial fibrillation, and congestive heart failure, and had an indwelling urinary catheter. On 12/16/2025, the resident’s potassium chloride dose was decreased for hypokalemia. On 12/23/2025, nursing documentation noted the resident was refusing to eat or drink with concern for dehydration, and new orders were obtained for a CBC with differential, a comprehensive metabolic panel, and a BNP to follow up heart failure, leukocytosis, and to rule out significant dehydration. On 12/26/2025, during a telehealth NP encounter prompted by increased confusion and reports from staff that the resident was hard to awaken and had decreased urinary output, an order was placed for a STAT urinalysis with reflex and culture and for staff to push oral fluids. Nursing documentation on 12/27/2025 at 5:17 A.M. indicated that a urine specimen was collected at 4:30 A.M. and placed in a refrigerator on the 100 hall to await laboratory pickup. Subsequent documentation showed that on 1/1/2026 the resident was lethargic but responsive to verbal stimuli and had swallowing difficulties, with food being held in the mouth or residual food after meals, whereas prior assessments had documented the resident as alert and oriented times three. On 1/2/2026, an NP monthly follow‑up encounter documented the resident as lethargic, barely responsive, hypotensive, hypoxic, with dry mucous membranes, tachypnea, diminished breath sounds, and applesauce with medication remaining in the mouth, and the resident was thought to be in acute respiratory failure with hypoxia and referred to the ED. A nursing note later that morning described the resident as initially interactive, then declining with hypotension, fluctuating oxygen saturations, non‑verbal status, moaning with movement, edema, generalized weakness, and difficulty swallowing, leading to a 911 call. Hospital evaluation that day revealed markedly elevated WBC, critically high potassium, severely elevated BUN and creatinine, and a urinalysis positive for UTI, with diagnoses including uremic encephalopathy, acute hypoxic respiratory failure, acute kidney injury, hyperkalemia, and pneumonia. In an interview, the DON stated that the ordered laboratory work had not been entered into the lab portal to be drawn and that the urinalysis specimen, although collected, was never picked up by the lab, and acknowledged that the ordered tests should have been completed.
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