F0684

D

Failure to Perform Ordered C-diff Test and Respond to Critical Lab Result for Resident With Persistent Diarrhea

Temecula, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a physician-ordered laboratory test was correctly carried out and that critical results and ongoing symptoms were appropriately communicated and addressed. A resident was admitted with diagnoses including encounter for surgical aftercare following digestive system surgery, major depressive disorder, and bipolar disorder, and had a POLST specifying comfort-focused treatment and transfer to the hospital only if comfort needs could not be met in the facility. On December 25, 2025, an SBAR form documented a change in condition with the onset of diarrhea and a primary clinician recommendation for a stool culture for C-diff. However, the order summary for that date showed only a generic stool culture was sent, and the facility did not complete the specific C-diff test that had been recommended.

From December 26 through December 31, 2025, bowel continence/movement records showed the resident repeatedly had loose and watery stools, with multiple entries documenting incontinence or continent episodes with large, medium, or small amounts of loose or watery stool. A stool culture result dated December 28, 2025, showed no salmonella or shigella, but there was no documentation that the physician was notified that the ordered C-diff culture had not been performed, nor that the resident continued to have loose stool over this seven-day period. Progress notes did not indicate any treatment for the resident’s ongoing loose stool. Facility staff, including an LVN and the ADON, later confirmed that a stool culture for C-diff is a different test from a routine stool culture and that the physician should have been notified when the wrong laboratory test was completed.

On December 31, 2025, an SBAR documented that the resident had significant weight loss over one week and drowsiness, with a recommendation for CBC and CMP. Laboratory results showed the resident’s WBC increased from 8.44 on December 23, 2025, to a critically elevated 36.91 on December 31, 2025. An SBAR at 11:39 p.m. recorded receipt of the critical WBC result but did not document any recommendations or interventions from the physician. RN 1 reported that she texted the physician with the critical value, received a question about the admission date, provided that information, and received no further response, and she endorsed the critical value to LVN 3. LVN 3 stated that a critical lab value is considered an emergency requiring an immediate phone call to the physician rather than a text message. The ADON confirmed that a WBC of 36.91 is a critical value, that the physician should have been notified, and that RN 1 should have followed up with the physician after the initial text response.

During the night shift spanning December 31, 2025, to January 1, 2026, LVN 3 monitored the resident every 30 minutes due to the critical lab value, performed a bladder scan, and noted the resident was easily aroused and not in distress around midnight. Later, he observed that the resident’s breathing became fast and labored, and he notified RN 1 and a CNA. An SBAR dated January 1, 2026, at 2:05 a.m. documented hypotension, bradycardia, tachypnea, and low oxygen saturation, with staff noting that the resident was initially without shortness of breath or distress around 12:45 a.m., but by around 2:00 a.m. had fast and labored breathing, prompting immediate RN assessment and a 911 call. Progress notes from January 1, 2026, described initiation of oxygen via non-rebreather mask, altered mental status, and the call to 911 at approximately 2:12 a.m., with transfer to the hospital and subsequent notification that the resident died in the ambulance at 2:38 a.m. The physician later stated he was not informed that the C-diff culture ordered on December 25, 2025, had not been performed and that, if the resident continued to have loose watery stool, a C-diff culture would have been important because a positive result would have led to antibiotic orders. The physician also stated he ordered the resident’s transfer to the hospital but was unaware of any delay in the transfer. The facility’s own policies required correct processing of lab orders, prompt physician notification of significant condition changes and critical lab results, and direct voice communication for results requiring immediate notification, which were not followed in this case.