Failure to Review and Communicate Critical Lab Result to Physician
Summary
The deficiency involves the facility’s failure to promptly review and communicate critical laboratory results to the attending physician in accordance with its Lab Monitoring and Lab Orders policies. A male resident with schizoaffective disorder, bipolar type, PTSD, and constipation, but no history or diagnosis of diabetes and no orders for insulin or blood glucose monitoring, reported abdominal discomfort and gastrointestinal issues. A nurse practitioner ordered a CBC and CMP after the resident complained of foul bowel odor, bad breath smell, and nausea. The following day, the lab drew the ordered tests, and the laboratory report showed a critically elevated blood glucose level of 934 mg/dL, with documentation that the critical result was called directly to the resident’s physician by the lab technician. The facility was not contacted by the lab, and there is no documentation that the physician notified the facility of the critical value. Facility staff did not identify or act on the critical lab result in a timely manner despite having access to the results through the Ring App and despite facility policy requiring that all lab results be reviewed by a nurse, dated and timed, and that critical values be called to the physician immediately. The 24-hour report noted that labs were done and described them as having a “negative outcome,” but did not document the critical glucose value or any physician notification. The ADON later printed the lab results from the Ring App and handed them to the nurse on duty, instructing her to contact or call the physician, but he stated he did not review the results himself. The nurse who received the printed results stated she did not review the lab values, assumed the ADON had already reviewed them, and only faxed them to the physician because the report indicated the physician was already aware. She did not confirm receipt of the fax and did not document any direct notification or follow-up with the physician regarding the critical value. Over the subsequent days, the resident continued to experience symptoms, including nausea and bowel issues, and asked staff about his lab results. One nurse directed him to ask another nurse, and the nurse who had been given the printed results denied that the resident asked her to read the results. On a later shift, another LVN observed that the resident appeared pale and was “talking differently,” prompting her to check his vital signs and then review the Ring App, where she saw the critically high glucose value of 945 mg/dL. She then checked the resident’s blood sugar with the facility glucometer and obtained a reading of 478 mg/dL, after which the resident was sent to the hospital. Interviews with the NP, Medical Director, ADONs, and nursing staff confirmed that the facility’s policies required nurses to review lab results, document the date and time of review, and promptly notify the physician of abnormal and critical values, and that this process was not followed for this resident’s critical glucose result. The failure to promptly notify the physician of the critical lab value and to follow the lab monitoring and lab orders policies constituted the deficiency. The report also documents that the facility’s Lab Monitoring policy required all lab results to be reviewed by a nurse, with the nurse dating and documenting the time the result was reviewed, and that critical lab results be called to the physician or on-call physician immediately. The Lab Orders policy required the facility to ensure timeliness of services, monitor lab orders daily, and ensure that all lab results were communicated to the physician in a timely manner, with proof of notification included on the lab report or in nurse’s notes. Interviews with the Administrator, ADON, and Medical Director confirmed that nurses were expected to review lab reports before forwarding them, to notify the physician of critical values, and not to assume that the physician had already been informed. In this case, multiple staff members acknowledged that the critical glucose value was not recognized or acted upon as required, and that the facility did not follow its own policies for lab review, tracking, and physician notification for this resident’s critical lab result.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple comorbidities, severe cognitive impairment, and an indwelling catheter had a urine culture that returned positive for MRSA following a physician-ordered UA. The abnormal result was obtained but not communicated to the physician for an extended period, and documentation showed the physician was not notified until much later, when an antibiotic was finally ordered for a UTI. The ADON confirmed the absence of timely notification in the record, despite a facility policy requiring nurses to review lab results and promptly notify the physician of significant abnormalities.
A resident with multiple fractures, thrombocytopenia, and hypertension had physician orders for a CBC and BMP that were not completed as ordered, as confirmed by medical record review and provider notes. A later set of CBC and BMP orders was carried out. The resident also had an order for a wound culture and sensitivity; the initial specimen was rejected by the lab due to use of an expired swab, and there was no documentation of an immediate recollection despite instructions to obtain a new specimen. The DON confirmed that the earlier labs were not completed and that the wound culture was collected with an expired swab and not recollected until a later date.
A resident with multiple complex conditions, including UTI, spinal cord issues, CKD, an unstageable pressure ulcer, and diabetes, had a physician order for weekly morning CBC, e-diff, platelets, BMP without glucose, and hepatic function panel during Meropenem therapy, with results to be sent to the physician. Record review showed that the ordered labs were not completed on two scheduled weeks, and the DON confirmed there was no evidence the labs were obtained as ordered.
The facility did not obtain or complete physician-ordered laboratory tests for three residents with complex medical needs, including those with diabetes and chronic illnesses. Despite orders for regular lab monitoring, required tests such as Hemoglobin A1C, TSH, Depakote levels, CBC, CMP, and uric acid were missed or not performed as scheduled. Staff interviews confirmed the absence of a tracking system for labs and no formal lab policy, resulting in missed tests for multiple residents.
A resident with multiple chronic conditions and urinary incontinence had a urinalysis and urine culture ordered by a nurse practitioner after reporting dysuria. Although the Medication Administration Record indicated the specimen was collected, interviews and record review confirmed the lab never received the sample, and the ordering provider was not notified of the missing results, contrary to facility policy.
A resident with multiple chronic conditions experienced a delay in UTI treatment due to the facility's failure to promptly obtain and report laboratory results to the provider. The order for a urinalysis and culture was not placed until two days after symptoms were noted, and the final lab results were not reported to the nurse practitioner for an additional three days, resulting in a delay in starting antibiotic therapy.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner of abnormal laboratory results for a resident. The resident was admitted with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, and had severe cognitive impairment and dependence on staff for activities of daily living, as well as an indwelling catheter. A physician order for a urinalysis was dated 06/11/25, and a urine culture completed on 06/14/25 showed a positive result for Methicillin Resistant Staphylococcal Aureus (MRSA). Despite the abnormal culture result on 06/14/25, review of the medical record showed no documentation that the physician was notified of these results until 06/27/25, when an order was obtained for Macrobid 100 mg by mouth twice daily for seven days for a urinary tract infection. During an interview, the ADON confirmed that the medical record did not contain documentation supporting timely notification of the physician regarding the abnormal lab results. The facility’s policy on lab and diagnostic test results required nursing staff to review results upon receipt, determine the urgency of communication based on the seriousness of abnormalities and the resident’s condition, and notify the physician using various possible communication methods.
Plan Of Correction
F773 Lab Srvcs Physician Order/Notify of Results The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Any of the residents receiving lab draws in the facility could be affected by this practice. A sweep of all residents receiving labs was done by DON/designee back to 3/2/2026 and the physician has been notified of all abnormal labs. Completed 3/25/26 Residents were not negatively affected as noted on the sweep. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced all nursing staff about notification of abnormal labs timely completed on 4/9/2026. The corrective action will be monitored to ensure the deficient practice will not recur. Daily audit of lab draws over the previous days not audited for MD and resident /family notification and follow through, are audited and DON/ADON are auditing that the physician is being notified next day any of all abnormal labs to ensure labs are not being missed. audits began 3/25/2026. All lab draws are audited daily. This audit is done 5xa week for 4 weeks with results presented to QAPI committee. concerns are corrected and staff reeducated.
Failure to Complete Ordered Labs and Wound Culture Timely
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered laboratory tests and wound cultures were completed in a timely manner for one resident. The resident was admitted with multiple serious diagnoses, including a right humerus fracture, wedge compression fracture of the second lumbar vertebra, multiple rib fractures, thrombocytopenia, and hypertension, and was later discharged. Physician orders dated on one occasion directed that a complete blood count (CBC) and basic metabolic panel (BMP) be obtained, but review of the medical record showed no evidence these blood tests were ever completed. A provider progress note confirmed that the labs ordered on that date were not done. A subsequent physician order for a CBC and BMP was carried out, and those labs were completed as ordered. The facility also failed to complete a wound culture and sensitivity as ordered in a timely manner. A physician ordered a wound culture and sensitivity, and a specimen was collected and reported by the laboratory. However, the lab report indicated the test was not performed due to specimen integrity issues, specifically that the facility had submitted an expired swab and was instructed to recollect a new specimen. The medical record contained no documentation that a repeat wound culture was obtained following this notification. A later physician order for a wound culture and sensitivity was eventually carried out, with the culture collected on a later date. In an interview, the DON verified that the ordered labs from the earlier date were not completed and confirmed that the wound culture specimen had been collected with an expired swab and was not recollected until a later date.
Failure to Obtain Ordered Weekly Laboratory Tests During Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain ordered laboratory tests and communicate results to the ordering practitioner for one resident. The resident was admitted with diagnoses including urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, an unstageable pressure ulcer, and diabetes. An admission MDS showed the resident had intact cognition but required extensive assistance with most activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. A physician’s order dated 12/04/25 directed that a CBC, electronic differential, platelets, BMP without glucose, and hepatic function panel be obtained weekly on Thursday mornings during Meropenem therapy, with results to be sent to the physician. Review of the medical record showed no evidence that the ordered labs were completed on 12/11/25 and 12/25/25, and in an interview the DON confirmed there was no evidence the labs were done as ordered. This was cited as an incidental finding of non-compliance under the referenced complaint number.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain and complete physician-ordered laboratory tests for three residents who required regular monitoring due to complex medical conditions. For one resident with diagnoses including diabetes mellitus, mood disorder, and other chronic illnesses, there was no evidence that Hemoglobin A1C or Depakote levels were completed after early August, nor that a TSH level was completed after early August, despite orders for these labs every three months. Another resident with multiple diagnoses such as acute respiratory failure, CHF, chronic kidney disease, and diabetes had orders for quarterly CBC, CMP, A1C, uric acid, and TSH tests, but none were completed after early June. A third resident with diabetes had a quarterly Hemoglobin A1C order, but no test was completed in September as required. Interviews with the DON and ADON confirmed that the ordered labs were not completed as scheduled and revealed there was no system in place for tracking when labs were due or completed. Additionally, facility leadership confirmed there was no formal lab policy, and staff relied solely on following physician orders without a structured process for ensuring compliance. These failures were identified during the review of medical records and staff interviews, affecting three residents reviewed for laboratory testing.
Failure to Obtain and Report Ordered Urinalysis
Penalty
Summary
A deficiency occurred when the facility failed to obtain a urinalysis for a resident as ordered by the nurse practitioner. The resident, who had a history of traumatic brain injury, hemiplegia, hypokalemia, chronic pain, chronic kidney disease stage three, stress incontinence, and irritable bowel syndrome, was admitted with ongoing urinary incontinence. On the date of the incident, the resident complained of burning with urination, and the nurse practitioner ordered a urinalysis and urine culture and sensitivity. The resident was aware of and agreed to the order. Despite documentation in the Medication Administration Record indicating that the urinalysis was collected, a review of the medical record, lab results, progress notes, physician notes, and the facility infection control log revealed no results for the urinalysis and no evidence that the ordering provider was notified about the missing results. Interviews with an LPN confirmed that the lab did not receive a urine specimen for the resident and that no provider was contacted regarding the absence of results. Facility policy required timely notification of lab results to providers, which was not followed in this instance.
Delay in Reporting Lab Results Led to Delayed UTI Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that laboratory results were obtained and reported to the provider in a timely manner, which delayed treatment for a urinary tract infection (UTI). A resident with multiple diagnoses, including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension, and malignant neoplasm of the large intestine, exhibited symptoms of a UTI and was seen by a nurse practitioner, who ordered a urinalysis with culture and sensitivity (UA C&S). However, the order for the UA C&S was not placed until two days after the initial assessment, and the urine sample was collected and sent to the lab on the same day the order was placed. The urinalysis indicated infection, and the urine culture, received by the facility three days later, confirmed the presence of Escherichia coli ESBL. Despite receiving the final urine culture results, the facility did not report these results to the nurse practitioner until three days after they were available. Only then was an antibiotic ordered and started for the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the delay in reporting the abnormal laboratory results to the provider, and the ADON was unable to provide a reason for the delay. Facility policy required prompt notification of the provider when there was a need to alter medical treatment, including changes in provider orders.
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