Failure to Notify Physician of Abnormal Potassium Result
Summary
Timely physician notification of clinically significant abnormal laboratory results was not ensured for one resident. Resident 87 was admitted with diagnoses including diabetes, dysphagia, and hypokalemia, and had moderately impaired cognition with a BIMS score of 12. Physician orders included potassium chloride 20 mEq by mouth twice daily and spironolactone 25 mg daily. A CMP obtained revealed abnormal values including elevated BUN, creatinine, reduced eGFR, and a potassium level of 5.2 mmol/L, with the potassium elevation occurring while the resident was receiving potassium-increasing medications. The clinical record did not show that licensed nursing staff notified the physician of the abnormal laboratory results after they were obtained. A nursing progress note later documented that the resident's daughter reported the resident was tired, not herself, and more confused, and the RN supervisor was notified, but there was still no documented evidence that the physician had been informed of the earlier abnormal lab findings or the change in condition. The resident continued to receive potassium supplementation and spironolactone as ordered after the abnormal potassium result was identified. A CRNP later evaluated the resident and ordered repeat laboratory testing. When repeat labs were drawn, the potassium level was critically high at 7.4 mmol/L, and the resident had increased confusion and complaints of crushing pain at the base of the neck. The physician was then notified and ordered immediate transfer to the emergency room. Hospital records showed the resident was admitted with hyperkalemia.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with multiple comorbidities, severe cognitive impairment, and an indwelling catheter had a urine culture that returned positive for MRSA following a physician-ordered UA. The abnormal result was obtained but not communicated to the physician for an extended period, and documentation showed the physician was not notified until much later, when an antibiotic was finally ordered for a UTI. The ADON confirmed the absence of timely notification in the record, despite a facility policy requiring nurses to review lab results and promptly notify the physician of significant abnormalities.
Failure to complete ordered lab tests for a resident with epilepsy, dysphagia, DM2, bipolar disorder, dementia, and gastrostomy status. The resident had significantly impaired cognition and depended on tube feeding for most nutrition and fluid needs. A physician ordered CBC with diff, BMP, and Hgb A1C every 6 months, but the chart showed the last labs were completed months earlier, and the Administrator confirmed no labs were done before the order was discontinued.
A resident with multiple fractures, thrombocytopenia, and hypertension had physician orders for a CBC and BMP that were not completed as ordered, as confirmed by medical record review and provider notes. A later set of CBC and BMP orders was carried out. The resident also had an order for a wound culture and sensitivity; the initial specimen was rejected by the lab due to use of an expired swab, and there was no documentation of an immediate recollection despite instructions to obtain a new specimen. The DON confirmed that the earlier labs were not completed and that the wound culture was collected with an expired swab and not recollected until a later date.
Ordered lab tests were not completed for a resident with acute kidney failure, severe protein calorie malnutrition, COPD, A fib, depression, anxiety, and weight loss. The resident’s orders included CBC, CMP, A1c, TSH, vitamin B12, and vitamin D, but the record showed no evidence the tests were done, and the DON confirmed the labs were not completed as ordered.
A resident with multiple complex conditions, including UTI, spinal cord issues, CKD, an unstageable pressure ulcer, and diabetes, had a physician order for weekly morning CBC, e-diff, platelets, BMP without glucose, and hepatic function panel during Meropenem therapy, with results to be sent to the physician. Record review showed that the ordered labs were not completed on two scheduled weeks, and the DON confirmed there was no evidence the labs were obtained as ordered.
The facility did not obtain or complete physician-ordered laboratory tests for three residents with complex medical needs, including those with diabetes and chronic illnesses. Despite orders for regular lab monitoring, required tests such as Hemoglobin A1C, TSH, Depakote levels, CBC, CMP, and uric acid were missed or not performed as scheduled. Staff interviews confirmed the absence of a tracking system for labs and no formal lab policy, resulting in missed tests for multiple residents.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner of abnormal laboratory results for a resident. The resident was admitted with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, and had severe cognitive impairment and dependence on staff for activities of daily living, as well as an indwelling catheter. A physician order for a urinalysis was dated 06/11/25, and a urine culture completed on 06/14/25 showed a positive result for Methicillin Resistant Staphylococcal Aureus (MRSA). Despite the abnormal culture result on 06/14/25, review of the medical record showed no documentation that the physician was notified of these results until 06/27/25, when an order was obtained for Macrobid 100 mg by mouth twice daily for seven days for a urinary tract infection. During an interview, the ADON confirmed that the medical record did not contain documentation supporting timely notification of the physician regarding the abnormal lab results. The facility’s policy on lab and diagnostic test results required nursing staff to review results upon receipt, determine the urgency of communication based on the seriousness of abnormalities and the resident’s condition, and notify the physician using various possible communication methods.
Plan Of Correction
F773 Lab Srvcs Physician Order/Notify of Results The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Any of the residents receiving lab draws in the facility could be affected by this practice. A sweep of all residents receiving labs was done by DON/designee back to 3/2/2026 and the physician has been notified of all abnormal labs. Completed 3/25/26 Residents were not negatively affected as noted on the sweep. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced all nursing staff about notification of abnormal labs timely completed on 4/9/2026. The corrective action will be monitored to ensure the deficient practice will not recur. Daily audit of lab draws over the previous days not audited for MD and resident /family notification and follow through, are audited and DON/ADON are auditing that the physician is being notified next day any of all abnormal labs to ensure labs are not being missed. audits began 3/25/2026. All lab draws are audited daily. This audit is done 5xa week for 4 weeks with results presented to QAPI committee. concerns are corrected and staff reeducated.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were completed per physician orders for one resident (#23) out of five reviewed for laboratory tests. Resident #23 was admitted with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status, and the quarterly MDS indicated significantly impaired cognition, a feeding tube, and reliance on tube feeding for 51% or more of nutrition and fluid needs. A physician order dated 10/03/24 and discontinued 02/26/26 required CBC with differential, BMP, and hemoglobin A1C every six months, but the resident's record showed the most recent laboratory tests were completed on 06/02/25. The Administrator confirmed on 03/05/26 that no laboratory tests had been completed for Resident #23 since 06/02/25 and before the order was discontinued.
Failure to Complete Ordered Labs and Wound Culture Timely
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered laboratory tests and wound cultures were completed in a timely manner for one resident. The resident was admitted with multiple serious diagnoses, including a right humerus fracture, wedge compression fracture of the second lumbar vertebra, multiple rib fractures, thrombocytopenia, and hypertension, and was later discharged. Physician orders dated on one occasion directed that a complete blood count (CBC) and basic metabolic panel (BMP) be obtained, but review of the medical record showed no evidence these blood tests were ever completed. A provider progress note confirmed that the labs ordered on that date were not done. A subsequent physician order for a CBC and BMP was carried out, and those labs were completed as ordered. The facility also failed to complete a wound culture and sensitivity as ordered in a timely manner. A physician ordered a wound culture and sensitivity, and a specimen was collected and reported by the laboratory. However, the lab report indicated the test was not performed due to specimen integrity issues, specifically that the facility had submitted an expired swab and was instructed to recollect a new specimen. The medical record contained no documentation that a repeat wound culture was obtained following this notification. A later physician order for a wound culture and sensitivity was eventually carried out, with the culture collected on a later date. In an interview, the DON verified that the ordered labs from the earlier date were not completed and confirmed that the wound culture specimen had been collected with an expired swab and was not recollected until a later date.
Ordered Laboratory Tests Not Completed
Penalty
Summary
The facility failed to obtain ordered laboratory tests for Resident #24, affecting 1 of 38 residents reviewed for laboratory tests. Resident #24 was admitted with diagnoses including acute kidney failure, severe protein calorie malnutrition, COPD, A fib, depression, anxiety, and weight loss. Her quarterly MDS assessment indicated that her cognition was intact and that she was independent with eating, oral hygiene, toileting, showering/bathing, dressing, and personal hygiene, with occasional urinary incontinence and continence of bowel. Physician orders dated 01/09/26 included CBC, CMP, A1c, TSH, vitamin B12, and vitamin D to be completed on 01/12/26, but the record showed no evidence that the blood tests were completed as ordered. On 01/20/26 at 10:02 A.M., the DON confirmed that the ordered laboratory tests had not been completed.
Failure to Obtain Ordered Weekly Laboratory Tests During Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain ordered laboratory tests and communicate results to the ordering practitioner for one resident. The resident was admitted with diagnoses including urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, an unstageable pressure ulcer, and diabetes. An admission MDS showed the resident had intact cognition but required extensive assistance with most activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. A physician’s order dated 12/04/25 directed that a CBC, electronic differential, platelets, BMP without glucose, and hepatic function panel be obtained weekly on Thursday mornings during Meropenem therapy, with results to be sent to the physician. Review of the medical record showed no evidence that the ordered labs were completed on 12/11/25 and 12/25/25, and in an interview the DON confirmed there was no evidence the labs were done as ordered. This was cited as an incidental finding of non-compliance under the referenced complaint number.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain and complete physician-ordered laboratory tests for three residents who required regular monitoring due to complex medical conditions. For one resident with diagnoses including diabetes mellitus, mood disorder, and other chronic illnesses, there was no evidence that Hemoglobin A1C or Depakote levels were completed after early August, nor that a TSH level was completed after early August, despite orders for these labs every three months. Another resident with multiple diagnoses such as acute respiratory failure, CHF, chronic kidney disease, and diabetes had orders for quarterly CBC, CMP, A1C, uric acid, and TSH tests, but none were completed after early June. A third resident with diabetes had a quarterly Hemoglobin A1C order, but no test was completed in September as required. Interviews with the DON and ADON confirmed that the ordered labs were not completed as scheduled and revealed there was no system in place for tracking when labs were due or completed. Additionally, facility leadership confirmed there was no formal lab policy, and staff relied solely on following physician orders without a structured process for ensuring compliance. These failures were identified during the review of medical records and staff interviews, affecting three residents reviewed for laboratory testing.
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