F0658

D

Failure to Complete and Communicate Ordered CBC Labs for a Resident

Los Angeles, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The facility failed to meet professional standards of quality by not ensuring that physician-ordered Complete Blood Count (CBC) laboratory tests were obtained for one resident. The resident was admitted with encephalopathy, dementia, and schizophrenia, and had severe cognitive impairment documented on the MDS, with limited ability to understand or be understood and no indication of rejecting care. The resident’s care plan for nutritional problems directed nursing and dietary staff to obtain and monitor laboratory work as ordered, report results to the physician, and follow up as indicated. A physician order dated 2/8/2026 directed that a CBC be drawn, but review of progress notes for February 2026 showed no indication that the CBC was completed, attempted, or refused, and no documentation that the physician was notified that the CBC was not done.

On 3/5/2026, a change of condition was documented when the resident developed cough with chest congestion, and the physician again ordered a CBC. A subsequent physician order dated 3/6/2026 specified that the CBC was to be drawn one time within three days. Review of progress notes from 3/1/2026 through 3/11/2026 showed no indication that this CBC was completed, attempted, or refused, and no documentation that the physician was notified that the ordered CBC was not done. During interviews, an LVN confirmed that neither the February nor March CBC orders were carried out within the required time frames and that there was no documentation of attempts, refusals, or physician notification. The DON also confirmed that the CBC orders were not performed and that staff should have contacted the lab vendor and notified the physician. The facility’s policy on physician notification indicated that physicians must be notified when laboratory results fall outside clinical reference ranges.