Missing Lab Results in Medical Records: The facility failed to keep lab reports accurately maintained and readily available in the medical record for two residents. One resident had ordered anemia-related labs, including ferritin, serum iron, transferrin, and TIBC, that were not found in the chart, and another resident had a TSH order with reflux to free T4 where the T4 was present but the TSH result was missing. The DON stated some results had to be manually printed from an external portal and scanned into the record, and that the missing TSH should have been in the chart.
Missing Lab Results in Resident Records: The facility did not keep complete lab records in the clinical charts for two residents. One resident with schizophrenia, OCD, dementia, and adult failure to thrive had ordered CBC, CMP, TSH, Depakote, ammonia, B12, and UA results that could not be located in the chart, while another resident with AFib, DM, anxiety, and bacteremia had ordered weekly CBC w/diff, CMP, CRP, and CK results missing from the record. RN and DON interviews confirmed the lab values were available on the portal or had been faxed, but were not filed in the residents' medical records.
Missing Laboratory Results in Resident Records: Survey review found that lab reports were not filed in the charts for multiple residents. Missing documentation included urine culture results, CBC, BMP, VIT D, CMP, ESR, and CRP results, and one CBC was later found to have been cancelled because the sample was clotted. Staff, including the DON and Corporate QA Nurse, were unable to locate the results in the medical records and obtained some reports directly from the lab website or lab after the surveyor requested them.
Missing Lab Results in Resident Record: A resident with chronic respiratory failure with hypoxia had ordered BMP, ABG, and Vitamin D labs marked completed, but the corresponding results were not found in the chart. Staff described a fax-to-chart process involving nursing review, physician review, and medical records scanning, yet the lab reports were still missing from the resident's medical record.
Missing Laboratory Results in Resident Records: The facility failed to maintain complete lab documentation in residents’ charts. For three residents, ordered labs such as CBC, CMP, BMP, urinalysis, wound culture, CRP, ESR, magnesium, ammonia, valproic acid, and a microalbumin creatinine ratio could not be located in the medical record. The DON and ADON stated the facility used a lab portal/website to access and print results, but the DON later could not locate one resident’s lab results in the record.
Missing laboratory results were found for a resident with amnesia, bipolar disorder, OCD, and drug-induced movement disorder. A physician ordered CBC, CMP, TSH, and lipid panel testing, but the results were not located in the EMR. RN and DON stated lab results are typically faxed, entered as a progress note, and filed in the resident's chart, but the ordered results had been sent to the physician's office instead of the facility.
A resident with spastic hemiplegia, immobility syndrome, and metabolic encephalopathy had UA testing and a urine culture ordered after provider evaluation, and notes documented that results were received and antibiotics were started. However, the urine culture lab report could not be located in the resident's chart, and the DON and HIM stated lab results should be uploaded to the medical record but could not explain why this report was missing.
Missing Laboratory Results in Resident Records: Two residents had ordered UA/C&S or UA with reflex to culture results that were not found in their EMR. One resident had orders related to hematuria, increased urine sediments, and UTI symptoms, and another had an order for follow-up post-UTI. The DON said the ADON printed and had the provider sign labs before they were uploaded, while Medical Records said he was behind on scanning and had not known the results needed to be entered in the results section.
Two residents with complex medical conditions had laboratory tests ordered, but the results were not filed in their clinical records. Staff interviews revealed that issues with the online lab portal and differences in handling STAT versus routine labs contributed to the missing documentation, as results were not consistently uploaded to the residents' medical records.
Two residents did not have all required laboratory results filed in their medical records, including a missing urine culture and a missing urine microalbumin result. The ADON confirmed that these results were not present in the records and had to be obtained from external sources.
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