Failure to Document Urine Culture Results
Summary
The facility failed to ensure that urine culture results were included in the medical record for a resident who was admitted with a diagnosis of urine retention. The resident, who was cognitively intact, had a urinalysis on 6/3/24 that indicated a pending urine culture. A Nurse Practitioner noted on 6/4/24 that the urinalysis was positive for leukocyte esterase and that they would await the culture results, as the resident was asymptomatic. However, the urine culture results, which were positive for Klebsiella pneumoniae and Escherichia coli, were not documented in the resident's medical record. The results were only obtained from the laboratory on 2/4/25 after being requested by the Nursing Home Administrator. The Director of Nursing reported that the culture results could not be located in the medical record and mentioned that physicians used a separate system for laboratory results.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident on transmission-based precautions had a physician-ordered urinalysis culture and sensitivity collected by a contracted lab, but the test results were not filed in the clinical record as required by facility policy. During record review, surveyors found no lab report in the chart, and the ADON/IP later produced a copy of the results and acknowledged they had not yet been filed. These findings were discussed with facility leadership during the exit conference.
The facility failed to maintain accurate records and reconciliation of controlled substances for two residents, resulting in medication discrepancies and diversion by an LPN. In both cases, oxycodone was signed out and administered without proper documentation or resident request, and required dual signatures for narcotic counts were missing across multiple shifts.
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.
A deficiency was identified when laboratory records in a resident's medical file were found to be incomplete and lacking required dates.
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.
Missing Lab Results in Medical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were accurately maintained and readily available in the medical record for 2 of 32 sampled residents. For Resident 3, who was admitted and later readmitted with diagnoses including hypo-osmolality, hyponatremia, and anxiety, a physician order dated 12/28/25 required additional labs for 12/29/25, including ferritin level, serum iron, transferrin, and TIBC for anemia. Those laboratory tests dated 12/29/25 were not located in Resident 3's medical record during review from 3/16/26 through 3/19/26. For Resident 4, who was admitted with diagnoses including vascular dementia, depression, PTSD, constipation, and prediabetes, a physician order dated 1/26/26 revealed a TSH with reflux to free T4. The record showed the T4 was completed on 1/26/26, but there were no TSH results in the medical record. During interview on 3/19/26, the DON stated the TSH had been completed but was not in the record and needed to be manually printed from an external portal and scanned into the medical record; the DON stated the TSH results should have been in the medical record.
Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including acute respiratory failure with hypoxia, Crohn's disease, and hemiplegia, multiple physician orders for laboratory tests such as Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Clostridioides difficile (C-diff) were documented, but the corresponding laboratory results were not found in the resident's medical record. Nursing progress notes and physician orders confirmed that these labs were ordered and should have been completed, yet no results were available in the record during the review period. For another resident with schizoaffective disorder, diabetes mellitus with kidney complication, and chronic kidney disease, an active physician's order for Glycated Hemoglobin (HgbA1C) to be drawn every six months was present, but no laboratory results were located in the medical record. Interviews with staff revealed that STAT lab results were typically faxed and reviewed by the provider, while routine labs were accessed through an online portal and were supposed to be uploaded to the resident's medical record by medical records staff. However, issues with the online portal and differences in how STAT and routine labs were managed led to missing documentation of lab results in the residents' records.
Incomplete and Undated Laboratory Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's record. This deficiency was identified through review of documentation, which revealed that laboratory records were either incomplete or missing required dates. The lack of proper documentation was directly observed in the resident's medical record.
Incomplete Filing of Laboratory Results in Resident Records
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including Lupus, major depressive disorder, dementia, anxiety, and a history of falls, a physician's order was placed for a urine analysis with culture. While the urine analysis result was present in the medical record, the urine culture result was missing. The Assistant Director of Nursing (ADON) confirmed that the culture results had not been filed in the medical record and had to be obtained by calling the laboratory. Similarly, another resident with Alzheimer's disease, type 2 diabetes, major depressive disorder, and anxiety disorder had a physician's order for multiple laboratory tests, including a urine microalbumin. Although most test results were documented, the urine microalbumin result was not found in the medical record. The ADON stated that she had to request the hospital to send the missing result so it could be attached to the medical record. In both cases, the required laboratory reports were not filed in the residents' clinical records as required.
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