F0770

D

Failure to Ensure Timely Completion of Ordered Laboratory Tests After Hospital Readmission

Raleigh, North Carolina Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that ordered laboratory tests were completed in a timely manner for a resident recently readmitted from the hospital with multiple serious diagnoses, including chronic kidney disease, diabetes, anemia, polyneuropathy, and congestive heart failure. After readmission, the resident was followed by a provider group in addition to her physician and was documented as cognitively intact. On 2/20/26, an NP documented that a nurse had reported the resident was short of breath without hypoxia and had a feeling of abdominal fullness, though she was functionally at baseline. In response, the NP made medication changes and ordered a CBC with differential, BMP, and BNP/NT proBNP to monitor kidney function, anemia, and infection risk.

The contracted lab company provided routine lab services six days per week, with the expectation that an order placed on a Friday would be drawn on Saturday if the requisition was in the lab book. The lab’s Risk Manager explained that the phlebotomist checked a lab book organized by date, signed a lab sheet each day, and was required to notify nursing and a lead phlebotomist if unable to obtain blood two days in a row. Review of the facility’s lab tracking forms showed the resident’s name listed for labs on 2/21/26, 2/24/26, and 2/25/26. On 2/21/26, the phlebotomist initialed the form, but there was no notation of refusal or inability to draw. On 2/24/26, the form contained only the notation “unable” by the resident’s name, with no further explanation. On 2/25/26, the resident’s name and labs again appeared with the phlebotomist’s initials at the top of the page and no notation that the labs were not drawn.

During this period, the resident reported that she had recently returned from the hospital with a new diagnosis of congestive heart failure, was more short of breath, and very tired. She stated that while hospitalized she had required blood and that labs were supposed to be drawn at the facility but had not been done. She recounted being told she had refused blood work while asleep on one morning, though she did not recall this, and later being told that her blood work had been completed despite having no signs of a blood draw and no recollection of it. On 2/26/26, she reported that she still had not had lab work drawn. The Unit Manager stated that when the phlebotomist signed at the top of the lab sheet without a notation by a resident’s name, staff understood that the labs had been completed, but in this case the labs ordered on 2/20/26 were not actually obtained until 2/26/26. The Administrator and Nurse Consultant confirmed that their system relied on the phlebotomist’s initials at the top of the lab sheets to indicate completion and that, based on this, they believed the labs had been done on 2/21/26 and 2/25/26, even though they had not.