F0770

D

Failure to Obtain Physician-Ordered Laboratory Tests

Arlington, Virginia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to obtain physician-ordered laboratory tests for two residents. For one resident (R6), the clinical record showed a physician’s order dated 2/11/26 for a Vancomycin trough level to start on 2/16/26 and to be obtained every Monday. Review of the resident’s clinical record did not contain laboratory results for the Vancomycin trough level that was due on 2/16/26. On 2/20/26, the DON stated she could not provide the laboratory results for that date. An LPN later explained that lab orders are entered and scheduled in the computer system, then written in a lab communication book; the night shift nurse is to verify labs due the next day and place a face sheet in the lab communication book, and an outside lab company obtains the lab on the due date. The facility did not provide a policy regarding laboratory services.

For another resident (R24), the facility staff did not obtain laboratory tests as ordered by the physician. The physician orders included labs that were to be completed on 1/20/2026, but the DON confirmed on 2/20/2026 that these lab tests were not completed as ordered and that there was no documentation explaining why the labs were done a day late. The Administrator, DON, General Manager, and Senior Director of Nursing Services were informed of these concerns during the survey, and no additional information was provided prior to exit.