Failure to Properly Enter and Process STAT Lab Orders Resulting in Delayed or Missed Diagnostics
Summary
The deficiency involves the facility’s failure to properly enter and process STAT and routine laboratory orders in the electronic medical record and the external lab portal, resulting in ordered labs not being drawn or not being treated as STAT for multiple residents. For one resident with dementia and hypertension, an ARNP ordered STAT CBC, CMP, chest x‑ray, and other diagnostics after the resident was noted with shortness of breath, labored breathing, and an oxygen saturation of 73% on room air. The LPN caring for the resident stated that the unit manager entered the labs into the lab website, but the lab company reported there was no phone call or requisition ticket for STAT labs and confirmed that no labs were drawn that day. Later that night, another LPN found the resident pale, gasping, with very low respirations and oxygen saturation despite oxygen, and a code blue was initiated with CPR and EMS transfer to the hospital. The PCP and ARNP both stated they were not aware the STAT labs had not been completed and expected the orders to be carried out and results communicated. Another resident with aphasia, hemiplegia, dementia, and a determination of incapacity had orders for CBC and CMP and, per staff and PCP interviews, was to have STAT labs, STAT chest x‑ray, flu and COVID swabs, nebulizer treatments, oxygen, and Ceftriaxone after presenting with fever over 102°F, oxygen saturation of 89%, labored breathing, and crackles in the lungs. The LPN who contacted the PCP reported that all labs and the chest x‑ray were ordered STAT, but the weekend supervisor entered the CBC and CMP as routine labs scheduled for a later date, and flu/COVID tests were not ordered until two days later. The medical record lacked documentation of the change in condition and the STAT nature of the orders on the day they were given. The resident’s labs were ultimately collected later, showing critically high sodium and other abnormal values, and the resident was later sent to the hospital with altered mental status, hypoxia, high fever, and was diagnosed with influenza A, septic shock, and multiorgan failure. A third resident, cognitively intact with diabetes, obesity, hypotension, and a gastrostomy, experienced vomiting, poor intake, and increased confusion. The provider ordered STAT CBC, CMP, and ammonia level for nausea, vomiting, and confusion. One LPN entered the STAT lab orders into the facility charting system while another LPN believed the first nurse would enter the orders into the lab system. The lab later reported that the orders were entered as routine, not STAT, and that while CBC and CMP were drawn and resulted, the ammonia level was not completed due to a specimen issue and was only noted in the portal. A fourth resident with atherosclerotic heart disease, Lewy body neurocognitive disorder, hypertension, and cardiomegaly had an episode of vomiting and chest pain with elevated blood pressure; the NP ordered IM medications, nitroglycerin, and STAT chest x‑ray, CBC, and CMP. The chest x‑ray was completed the same evening, but the CBC and CMP were entered as routine and not drawn until the next morning, with the lab confirming they were not processed as STAT. The DON and PCP acknowledged that the timing between ordering and completion was not acceptable for STAT labs and that there were problems with the lab process and nursing follow‑through on STAT orders.
Removal Plan
- The Director of Nursing was educated by the Regional Nurse Consultant on the process to review clinical records to validate diagnostic testing was completed per provider orders and that providers were notified of results.
- The Director of Nursing reviewed clinical records of current residents with diagnostic test orders from the prior 30 days to validate labs/diagnostic tests were completed as ordered and notified providers of any discrepancies.
- The Assistant Director of Nursing/Staff Development Coordinator began educating licensed nurses on the process to obtain STAT labs from the current lab service.
- The ADON/SDC educated licensed nurses on the process to obtain STAT labs from the current lab service.
- The Staff Development Coordinator began competency validation for licensed nurses on the process for obtaining routine and STAT labs.
- Step-by-step instructions for obtaining labs through the lab website (including STATs) were placed in the front of each lab binder.
- Licensed nurse education on the lab process, provider notification, and documentation was completed for nurses (with sign-in sheets and voice/text education reports used to validate completion).
- An ad hoc QAPI was completed with the Medical Director, Administrator, Director of Nursing, and additional IDT members addressing adherence to policy/process for change in condition, following provider orders, obtaining STAT labs, reviewing diagnostic results, and notifying providers; discussion included provider access to the EMR and ability to view lab/diagnostic results.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Urine Culture and Sensitivity Not Obtained as Ordered: A resident with a suprapubic catheter, quadriplegia, and a history of UTI had cloudy, odorous urine and diaphoresis. Urology ordered the catheter changed and urine collected for C&S, but although the specimen was placed in the specimen refrigerator, no C&S results were received and the DON later verified the lab had no record of the specimen being picked up.
A resident with an indwelling catheter, nephrostomy tubes, and diagnoses including cystitis with hematuria and bladder cancer reported blood-tinged urine in a nephrostomy bag. An NP instructed staff to obtain a urine C&S, but the sample was not collected and no corresponding order appeared in the order recap. Later review showed only one urine test in the reviewed period, and the RN verified the ordered test was not completed.
Delayed Communication of Lab Results: A resident with DM, UTI, dysphagia, and impaired cognition had CBC and BMP results received by the facility in the evening, but the RN did not review and send them to the physician until the next morning. The DON confirmed the results should have been communicated promptly, and the facility policy required the attending physician to be notified as soon as test results were received.
Failure to Obtain Ordered BNP and TSH Labs: A resident with CHF, COPD, CAD, HTN, malnutrition, and moderate cognitive impairment had provider orders for a BNP to assess HF status and a TSH to monitor thyroid function while on Synthroid. When the ADON produced lab results, the BNP and TSH could not be found, and the ADON said she had even called the lab; the ordering provider later stated he did not remember the orders but suspected the BNP should have been completed if the other labs were done.
A resident with dysuria had urine testing ordered, and the lab later reported culture results showing the organism was resistant to Ciprofloxacin. Facility staff did not promptly notify the ordering practitioner of the culture result, and the resident continued receiving Ciprofloxacin before the MD was informed and changed the antibiotic to Keflex.
A resident receiving anticoagulant monitoring had an INR ordered as a repeat test after a subtherapeutic result, but the lab was not completed as ordered. Record review showed no INR report for the ordered draw, and an LPN confirmed the test was not done.
Urine Culture and Sensitivity Not Obtained as Ordered
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity test was obtained timely and as ordered for a resident with an indwelling suprapubic catheter. The resident had multiple diagnoses including quadriplegia, extended spectrum beta lactamase, neurogenic bowel, chronic respiratory failure, urinary tract infection, neuromuscular dysfunction of the bladder, chronic pain syndrome, diabetes, seizures, and hydronephrosis with ureteral stricture. A quarterly MDS assessment documented intact cognition and an indwelling catheter. On 05/19/26, the resident was noted to be diaphoretic with elevated blood pressure, and the catheter was draining cloudy, odorous urine. The catheter was flushed and continued draining, urology was contacted, and the nurse practitioner ordered a CBC and BMP. On 05/20/26, urology returned the call and ordered the suprapubic catheter changed in house, urine collected for culture, results faxed to urology, and minocycline started. The catheter was changed and the specimen was collected and placed in the specimen refrigerator, but the record contained no urine culture and sensitivity results from 05/20/26 through 05/29/26. The Corporate DON later verified the laboratory never received the specimen and had no record of the urine culture and sensitivity being picked up.
Failure to Obtain Ordered Urine Culture and Sensitivity
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity was obtained after an NP recommended it for a resident who reported blood-tinged urine in a nephrostomy bag. The resident had been admitted with diagnoses including heart failure, diabetes, acute cystitis with hematuria, acute kidney failure, and malignant neoplasm of the bladder, and nursing documentation noted she denied pain when she reported the blood-tinged urine. The NP was notified and instructed staff to obtain a urine sample for culture and sensitivity, but the record showed no urine culture was collected on that date and no order for the urine sample was present in the physician order recap. Record review showed the resident had impaired cognition, an indwelling catheter, and later care plans addressed alteration in elimination related to bilateral nephrostomy tubes and risk for urinary tract infection complications. Review of laboratory reports showed only one urine test during the reviewed period, collected later and resulting in growth of pseudomonas aeruginosa carbapenem resistant and klebsiella pneumoniae. During interview, the resident stated she had recently seen a urologist who capped the nephrostomy tubes and that she currently only had an ostomy; she denied current blood or pain. The RN verified the urine sample was not collected per the NP's recommendation and stated she was not sure why, and the facility policy stated staff would process test requisitions and arrange for tests.
Delayed Communication of Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results for one sampled resident were communicated to the physician in a timely manner. Resident 1 was admitted and later readmitted to the facility with diagnoses including type 2 DM, muscle weakness, need for assistance with personal care, dysphagia, UTI, history of falling, and depression. The resident’s H&P stated the resident had the capacity to understand and make decisions, while the MDS later indicated severely impaired cognition and dependence or assistance with several activities of daily living. A CBC and BMP were completed for Resident 1 and the laboratory report showed the results were sent to the facility at 9:41 p.m. RN 3 reviewed the results the next morning at 6:59 a.m. and confirmed during interview that he then sent the results to the resident’s physician. RN 3 stated he worked the 7 a.m. to 3 p.m. shift. The DON reviewed the same laboratory results and confirmed they were received by the facility on the evening they were sent, and stated the results should have been sent to the physician as soon as possible and should not have waited until the next day. The facility policy stated that when test results are provided to the facility, the attending physician shall be promptly notified and that the charge nurse receiving the results is responsible for notifying the physician.
Failure to Obtain Ordered BNP and TSH Labs
Penalty
Summary
The facility failed to obtain provider-ordered laboratory tests for one resident, including a BNP and a TSH level. The resident was admitted with a medical history that included acute on chronic congestive heart failure, COPD, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS assigned a BIMS score of 8, indicating moderate cognitive impairment. A history and physical note signed by the Medical Director ordered a BNP to assess the resident’s current heart failure status, along with CBC, CMP, and magnesium levels. A provider progress note later ordered a TSH level because the resident had a history of hyperthyroidism and was receiving Synthroid 50 mg daily. When the ADON provided lab results, the BNP and TSH could not be produced, and the ADON stated, "I even called the lab." The ordering provider later stated he did not remember the orders but suspected the BNP should have been done if the other labs were completed.
Delayed Notification of Urine Culture Results
Penalty
Summary
The facility failed to promptly notify the ordering physician or clinical practitioner of a laboratory result for one resident. The resident had been assessed by the attending physician for discomfort during urination, declined a genitourinary examination, and was ordered to have a urinalysis and urine culture obtained. Nursing staff collected the urine specimen and sent it to the lab, and the urinalysis results were forwarded to the facility and later reported to the attending physician, who then ordered Ciprofloxacin for cystitis. The urine culture results were forwarded to the facility and showed abnormal findings, including that Ciprofloxacin was resistant to the organism identified. A nursing progress note later documented that the attending physician was made aware of the urine culture results, and the physician discontinued Ciprofloxacin and started Keflex for a urinary tract infection. The resident received additional doses of Ciprofloxacin after the facility had already been notified by the lab that the organism was resistant to that antibiotic.
Missed INR Lab Order for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one resident who was being monitored for anticoagulant therapy. Resident #5 had a physician order for an INR to be drawn on 4/27/26, but review of the medical record showed no INR laboratory report for that date. An After-Hours Telehealth Consult note dated 4/26/26 documented that the resident’s INR was subtherapeutic based on lab results from 4/26/26, and the provider ordered a repeat INR for 4/27/26. During interview on 4/29/26, an LPN confirmed that the INR was not completed as ordered.
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