F0770

E

Failure to Obtain and Monitor Physician-Ordered Laboratory Tests

Salina, Oklahoma Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The facility failed to ensure laboratory tests were obtained as ordered by physicians for two residents. Facility policy titled "Lab and Diagnostic Test Results-Clinical Protocol" dated November 2018 stated that physicians would order diagnostic and lab testing based on residents' needs and staff would process test requisitions and arrange for tests. For one resident, a physician order dated 04/11/25 required a CBC and CMP every six months in April and October. The resident’s quarterly assessment dated 10/31/25 documented a BIMS score of 2, indicating severe cognitive impairment for daily decision making, and no current pressure ulcers. The care plan, revised 10/31/25, identified the resident as at risk for pressure ulcers and directed staff to monitor labs as ordered by the physician. Record review showed that the ordered labs were not completed in April or October 2025, and the DON confirmed the labs had not been completed and could not explain why.

For a second resident, a physician order dated 03/12/24 required a CBC, CMP, LFT, and Valproic Acid level every six months in April and October. An annual assessment dated 10/09/25 showed the resident was severely impaired in cognition for daily decision making and had hypertension. The care plan, revised 10/09/25, documented hypertension and directed staff to monitor labs as ordered. Clinical record review did not show that the ordered labs were completed in October 2025. The DON stated that these labs had not been completed and reported they were supposed to monitor lab reports monthly but did not know why that monitoring was not being done.