F0773

D

Failure to Obtain and Communicate Ordered Laboratory Results

Brackenridge, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility failed to obtain and document laboratory results as ordered by physicians and failed to document notification of those results to the ordering practitioners and resident representatives for two of three residents reviewed. For one resident with diagnoses including stroke, hemiplegia, and urinary tract infection, a physician order dated 2/18/26 directed staff to obtain a CMP in the morning for monitoring. The clinical record contained no documentation that the CMP results were obtained, and there was no evidence that the physician or the resident representative were notified of any results. An LPN stated that the lab results were not in the clinical record and that she did not have access to the computer system where lab results are stored, indicating only the supervisor had such access.

For another resident with diagnoses including anemia, heart failure, and hypertension, a physician order dated 2/11/26 directed staff to obtain a one-time BMP on 2/12/26. The clinical record contained no documentation that the BMP results were obtained, and there was no evidence that the physician or the resident representative were notified of the results. The resident’s representative reported that blood work had been done a few weeks prior and that, despite multiple inquiries, no one could provide the lab results. The same LPN again indicated that lab results were not in the clinical record and that she lacked access to the lab computer system. The DON confirmed that the facility failed to obtain laboratory results as ordered and failed to provide evidence of notification to the physician or resident representative for these two residents, in violation of facility policies on laboratory services/reporting and change in condition/status, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.