Failure to Obtain Lab Tests Leads to Resident's Psychotic Episode and Injury
Summary
The facility failed to obtain and provide necessary laboratory tests for a resident on Clozapine, an antipsychotic medication, which led to a significant health event. The resident, diagnosed with paranoid schizophrenia, had a physician's order for regular blood tests to monitor potential side effects of Clozapine. However, the required laboratory tests were not conducted as ordered on the specified date, and the results were not sent to the pharmacy, which was necessary for the medication's renewal. The oversight occurred when a nurse failed to place the necessary paperwork in the laboratory book, resulting in the phlebotomist not having the information needed to draw the resident's blood. Consequently, the pharmacy did not receive the required lab results, leading to the medication being put on hold. The resident missed several doses of Clozapine, which is known to cause rebound psychosis if abruptly stopped. This resulted in the resident experiencing an acute psychotic event, during which he fell and sustained serious injuries, including a broken shoulder and hip. Interviews with staff, including the nurse practitioner and pharmacist, revealed that the facility was aware of the requirement for lab tests before dispensing Clozapine. Despite this, the necessary steps were not taken to ensure the tests were completed and communicated to the pharmacy. The failure to follow through with the lab orders and communicate results led to the resident's medication being withheld, contributing to the resident's psychotic episode and subsequent injuries.
Removal Plan
- Resident #11's medication could not be administered as ordered by the provider due to it not being available. The nurse notified the pharmacy of the medication not being available to administer. The pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. The provider was notified, and an order was obtained to draw stat lab work. The results of the labs were received and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. The nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy, the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy. The pharmacy dispensed the medication. The facility received Resident #11's medication. Resident #11's medication of Clozapine was administered to the resident as ordered by the provider.
- An audit of all current residents was completed by the Director of Nursing to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of not obtaining lab services as ordered by the provider.
- Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- Education was provided by the Director of Nursing to licensed staff and licensed agency staff that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- The Quality Assurance team met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; when the order appears on the medication administration record the licensed nurse ensured the lab results were faxed to the pharmacy, and the results were received and faxed to pharmacy when applicable. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent an omission of ordered lab services with ordered lab work through the weekend reviewed for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for review and, if warranted, further action.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of fractures and chronic diastolic HF developed new swelling, hardness, and warmth in the right arm and hand after cast removal. Nursing staff documented the change and a venous ultrasound of the upper extremity was ordered, but despite follow-up with a mobile radiology vendor, the doppler study was not performed as expected. Several days later, the ultrasound was completed and showed an occlusive radial DVT. Staff interviews and job descriptions confirmed that CNAs, LPNs, and RNs were expected to promptly report changes in condition, notify physicians, and follow up with outside vendors the same shift when ordered tests were not completed, yet there was an unexplained delay in obtaining the ordered diagnostic test.
Failure to Complete Ordered Lab Monitoring: A resident with a stage 4 pressure ulcer, vitamin D deficiency, diabetes, kidney disease, and dementia did not have ordered Albumin and Pre-Albumin labs completed on schedule, and ordered yearly Vitamin D and lipid panel testing was not documented as obtained. The physician expected labs to be done as ordered, while the LVN, DON, and Administrator each stated labs were supposed to be tracked and completed through the facility’s routine process, but the DON was unaware the resident was missing labs until surveyor intervention.
A resident with a history of falls, hemiparesis after stroke, type II diabetes, urinary incontinence, and severe cognitive impairment experienced a fall and had a care plan intervention for labs and a UA to be collected afterward. An LVN documented that an NP ordered both a CBC and UA as part of the post-fall evaluation, but only the CBC was coordinated and completed; no UA order appeared in the physician’s orders, and no UA was obtained. In interviews, the NP stated it would be reasonable for her to order a CBC and UA to assess for infection and possible cause of falls, while the LVN stated she believed the NP only ordered a CBC and that the UA would be contingent on UTI symptoms. The DON and Administrator stated that nurses are expected to implement prescribers’ orders and that the LVN was responsible for coordinating the UA but did not, potentially denying prescribers needed lab information.
A resident with a history of UTI reported dysuria, and the physician ordered a UA flex to culture and later prescribed Macrobid pending urine C&S results. Facility policy required timely laboratory services and specified that the day shift nurse complete and send lab requests. Although the UA was completed and results communicated to the physician, review of lab records showed no urine C&S was ever performed. The NHA confirmed that the lab order was transcribed incorrectly, so the C&S test was not completed as ordered.
The facility failed to ensure timely review and communication of critical and STAT PT/INR lab results for two residents on anticoagulation therapy. In one case, a resident’s critically high PT/INR result was available in the lab system and fax attempts failed, but nursing staff did not review the result until the next day and the MD was not notified when the result became available. In another case, a STAT PT/INR result was not phoned to the facility by the contracted lab, and nursing staff did not check the lab system and review the result until nearly a full day later. Leadership acknowledged that critical and STAT labs are expected to be called by the lab and that nurses are also expected to monitor the electronic lab system, but these processes did not occur as required.
A resident receiving anticoagulation therapy for an upper extremity thrombosis had multiple physician orders for INR testing, and blood was reportedly drawn, but PT/INR tests were not completed and no lab results were documented for several ordered test dates. The DON acknowledged that although lab orders were placed correctly, the anticoagulation testing was not performed, and the physician reported frequently ordering INRs without receiving any results. The resident was later hospitalized with a supratherapeutic INR of 12.0 and a markedly prolonged PT, while the facility was unable to provide a relevant policy during the survey.
Delay in Venous Ultrasound for Symptomatic Resident
Penalty
Summary
The facility failed to provide timely diagnostic testing for a resident who developed new swelling in the right arm and hand. The resident, admitted with diagnoses including a right radius fracture, right ulna styloid fracture, chronic diastolic heart failure, and convulsions, had previously had a cast removed from the right arm. On the evening of 3/13/2026, nursing documentation noted swelling of the right arm and hand that felt hard and slightly warm to the touch, with range of motion within normal limits, and indicated that hospice and the facility physician were notified. In the early morning of 3/14/2026, a new order was placed for a venous ultrasound of the right upper extremity. On 3/15/2026 at 9:56 p.m., a nursing note documented that staff called the mobile radiology vendor about the ordered doppler, were told someone would come that day, but the vendor had not arrived to perform the test. The venous ultrasound was ultimately completed on 3/17/2026 at 11:01 a.m., revealing an occlusive radial deep venous thrombosis. The resident’s care plan identified risk for cardiac complications and included interventions to notify the physician of significant abnormalities and to observe, document, and report changes in color or warmth of extremities. Staff interviews indicated that CNAs were expected to report swelling to nurses immediately, and LPNs were expected to report changes in condition, including swelling, right away, with follow-up to outside vendors within the same shift if ordered radiology services did not occur. The DON stated that swelling in residents with chronic heart failure should be reported immediately, including on night shift, and that staff must call outside vendors again if they did not arrive to perform ordered procedures. Despite these expectations and position descriptions requiring LPNs and RNs to observe, report, and coordinate care with physicians and other health care team members, there was an unexplained delay between the identification of swelling, the ordering of the venous ultrasound, and the completion of the test.
Failure to Complete Ordered Lab Monitoring
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of Resident #12. The record showed orders for Albumin to be drawn monthly and Pre-Albumin to be drawn bi-weekly to assist the registered dietitian with nutritional assessment and pressure wound care, but the resident's electronic medical record did not show the ordered labs were completed as scheduled. The record also showed orders for Vitamin D and Lipid panel testing yearly, and the electronic medical record did not indicate that either test had been obtained since the orders were placed. Resident #12 was an [AGE]-year-old male with diagnoses including a stage 4 pressure ulcer, vitamin D deficiency, diabetes, kidney disease, and dementia. The comprehensive care plan identified that he was at risk for complications related to vitamin D deficiency and impaired thought process related to liver cirrhosis, with interventions that included labs as ordered, medication as ordered, and observation for complications. A later care plan revision again identified him as at risk for complications related to wounds and included labs as ordered. During interviews, the physician stated he expected labs to be done as ordered. The LVN said nurses were responsible for completing lab slips, placing new orders on the 24-hour report, and checking the lab book daily for routine labs, and she was not aware of any missed labs for Resident #12. The DON and Administrator both stated they expected labs to be drawn as ordered and said nurse management was responsible for ensuring completion; the DON also stated he was unaware the resident was missing labs until the surveyor intervention. The facility policy stated laboratory services would be performed as ordered by the physician and completed on the date specified or the next scheduled lab day if no specific date was identified.
Failure to Obtain Ordered Urinalysis After Resident Fall
Penalty
Summary
The facility failed to provide or obtain ordered laboratory services for one resident when an LVN did not secure a urinalysis (UA) as part of the evaluation after a fall. The resident was an elderly female with a history of falling, hemiparesis following a cerebral infarction affecting the left side, and type II diabetes, admitted for LTC and assessed with severe cognitive impairment (BIMS score of 3/15). Her care plan documented urinary incontinence, monitoring for signs and symptoms of UTI, a history of falls, and an intervention for labs and a UA to be collected following an actual fall on 04/07/2026, with the UA to be initiated on 04/08/2026. A nursing progress note by LVN G on 04/08/2026 at 11:20 AM stated that the NP ordered a CBC and UA as part of the action plan for the recent fall. A review of the physician’s orders from 04/01/2026 through 04/24/2026 showed no order for a UA, and the UA was never completed. During interview, the NP stated she could not recall the specific report from the LVN about the fall but indicated it would be reasonable for her to order a CBC and UA to assess for potential infection and possible rationale for falls. In a separate interview, LVN G stated that the NP requested only a CBC and that she coordinated and obtained that lab draw. LVN G further stated that, although her note documented that the NP wanted both a blood draw and a UA, the note was not complete and should have indicated that the UA was to be done only if the resident showed UTI symptoms such as confusion, dysuria, or foul-smelling urine; therefore, she believed no UA order was in place and did not obtain one. In a joint interview, the DON and Administrator stated that nurses were expected to support and implement prescribers’ new orders and that LVN G was responsible for coordinating the NP’s order for a UA and had not done so, which they stated could deny prescribers the opportunity to intervene by not having laboratory services reported.
Failure to Obtain Ordered Urine Culture and Sensitivity Test
Penalty
Summary
The facility failed to obtain ordered laboratory services for a resident when a urine culture and sensitivity (C&S) test was not completed as ordered by the physician. Facility policy dated January 22, 2026, stated that the facility would provide or obtain laboratory services to meet residents' needs and ensure quality and timeliness, with the day shift unit nurse responsible for filling out and sending laboratory requests for newly ordered tests. A quarterly MDS for the resident, dated March 29, 2026, documented that the resident was cognitively intact, independent with daily care needs, and had a history of urinary tract infection. On February 24, 2026, at 1:31 p.m., nursing documentation showed that the resident complained of burning and pain on urination, the physician was notified, and an order was received for a UA flex to culture to rule out a urinary tract infection. Later that day at 5:58 p.m., a nurse's note indicated that the physician was notified of the urinalysis results and ordered Macrobid 100 mg twice daily for seven days pending the urine C&S results. Review of the February 2026 lab results revealed no evidence that a urine C&S was obtained from the February 24 urine sample as ordered. In interviews, the Nursing Home Administrator confirmed that a urine C&S was not obtained as ordered and explained that the laboratory order for the resident’s urine sample had been transcribed incorrectly, resulting in the C&S not being completed by the lab.
Plan Of Correction
The facility is unable to retroactively correct the observation of a Urinalysis (UA) being completed when a Urinalysis with Culture and Sensitivity (UA C&S) was ordered. There were no ill effects noted. The Director of Nursing and/or designee will re-educate the current in-house and agency Nursing Staff regarding obtaining laboratory services per physician order and assuring that the laboratory requisition is completed correctly and per physician order. Newly hired and agency Nursing staff will be educated regarding obtaining laboratory services per physician order and assuring that the laboratory requisition is completed correctly and per physician order. Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that UA and UA C&S specimen laboratory requisitions are accurate per physician order. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Timely Review and Communicate Critical and STAT Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting and review of STAT and critical laboratory results, as well as the absence of a lab policy. One resident with diagnoses including anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and COPD had orders for PT/INR testing twice weekly and warfarin dosing with instructions to contact the physician with PT/INR results. A PT/INR drawn showed a PT of 70.4 and a critically high INR of 7.0, but there was no documentation that the physician was notified of these elevated results on the day they were available. The Medical Director confirmed that the critical result was not called to her on the day of the test and that she only became aware of it the following day. The Unit Manager stated that critical labs are supposed to be called to the provider and that nurses are instructed to check the lab system, but acknowledged that although the results were available, she did not see them until the next morning. A RN also reported not being aware of the PT/INR result until several days later. For another resident with diagnoses including hypoosmolality and hyponatremia, morbid obesity, pulmonary embolism, and hypertension, physician orders included weekly PT/INR and a STAT PT/INR for elevated lab levels. A STAT PT/INR result showed a PT of 31.9 and an INR of 3.1, but there was no documentation that the lab called these STAT results to the facility. The DON and ADON stated that critical and STAT labs are usually called from the lab, but also confirmed that nurses are expected to check the lab system. They acknowledged that the lab did not call the STAT results and that the nurse did not review the lab tests until nearly 22 hours after they were available. The contracted lab’s representative reported that the critical PT/INR result for the first resident was released into the system in the evening, that nurses had access at that time, and that fax attempts failed twice. The lab contract specified that critical and STAT results would be phoned to the facility when available and that STAT testing would be reported within five hours, which did not occur in these instances.
Failure to Monitor Anticoagulation Lab Results Leading to Supratherapeutic INR
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete laboratory monitoring of a resident’s anticoagulation therapy. The resident had a diagnosis of thrombosis of the right upper extremity and was receiving anti-clotting medication regulated by INR (International Normalized Ratio) testing. A physician’s order dated 03/02/2026 directed that an INR blood test be drawn, and the DON stated that the blood was drawn on 03/03/2026. However, the resident’s medical record contained no results for this INR order, and the DON reported that although the laboratory orders were placed correctly, the PT (Prothrombin Time) and INR tests were not completed. The resident’s prior INR result in the record was from 01/16/2026, with an INR of 1.2, and no subsequent INR results were documented for the ordered tests. According to the DON, additional INR tests were scheduled on 03/13/2026, 03/14/2026, 03/16/2026, 03/17/2026, and 03/18/2026, but no INR results were obtained for any of those dates. The resident was later discharged from the facility and admitted to the hospital, where hospital laboratory results on 03/19/2026 showed a PT of 96.6 seconds (normal 12.3–15.1) and an INR of 12.0 (normal 0.8–1.2). The attending physician explained that a supratherapeutic INR indicates too much Coumadin, that the resident’s therapeutic INR range should have been 2–3, and that INR levels are used to regulate the resident’s anti-clotting medication. The physician stated that INR tests were ordered frequently at the facility but that no laboratory results were received. The facility did not provide a policy related to this issue at the time of the survey.
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