Failure to Properly Enter and Process STAT Lab Orders Resulting in Delayed or Missed Diagnostics
Summary
The deficiency involves the facility’s failure to properly enter and process STAT and routine laboratory orders in the electronic medical record and the external lab portal, resulting in ordered labs not being drawn or not being treated as STAT for multiple residents. For one resident with dementia and hypertension, an ARNP ordered STAT CBC, CMP, chest x‑ray, and other diagnostics after the resident was noted with shortness of breath, labored breathing, and an oxygen saturation of 73% on room air. The LPN caring for the resident stated that the unit manager entered the labs into the lab website, but the lab company reported there was no phone call or requisition ticket for STAT labs and confirmed that no labs were drawn that day. Later that night, another LPN found the resident pale, gasping, with very low respirations and oxygen saturation despite oxygen, and a code blue was initiated with CPR and EMS transfer to the hospital. The PCP and ARNP both stated they were not aware the STAT labs had not been completed and expected the orders to be carried out and results communicated. Another resident with aphasia, hemiplegia, dementia, and a determination of incapacity had orders for CBC and CMP and, per staff and PCP interviews, was to have STAT labs, STAT chest x‑ray, flu and COVID swabs, nebulizer treatments, oxygen, and Ceftriaxone after presenting with fever over 102°F, oxygen saturation of 89%, labored breathing, and crackles in the lungs. The LPN who contacted the PCP reported that all labs and the chest x‑ray were ordered STAT, but the weekend supervisor entered the CBC and CMP as routine labs scheduled for a later date, and flu/COVID tests were not ordered until two days later. The medical record lacked documentation of the change in condition and the STAT nature of the orders on the day they were given. The resident’s labs were ultimately collected later, showing critically high sodium and other abnormal values, and the resident was later sent to the hospital with altered mental status, hypoxia, high fever, and was diagnosed with influenza A, septic shock, and multiorgan failure. A third resident, cognitively intact with diabetes, obesity, hypotension, and a gastrostomy, experienced vomiting, poor intake, and increased confusion. The provider ordered STAT CBC, CMP, and ammonia level for nausea, vomiting, and confusion. One LPN entered the STAT lab orders into the facility charting system while another LPN believed the first nurse would enter the orders into the lab system. The lab later reported that the orders were entered as routine, not STAT, and that while CBC and CMP were drawn and resulted, the ammonia level was not completed due to a specimen issue and was only noted in the portal. A fourth resident with atherosclerotic heart disease, Lewy body neurocognitive disorder, hypertension, and cardiomegaly had an episode of vomiting and chest pain with elevated blood pressure; the NP ordered IM medications, nitroglycerin, and STAT chest x‑ray, CBC, and CMP. The chest x‑ray was completed the same evening, but the CBC and CMP were entered as routine and not drawn until the next morning, with the lab confirming they were not processed as STAT. The DON and PCP acknowledged that the timing between ordering and completion was not acceptable for STAT labs and that there were problems with the lab process and nursing follow‑through on STAT orders.
Removal Plan
- The Director of Nursing was educated by the Regional Nurse Consultant on the process to review clinical records to validate diagnostic testing was completed per provider orders and that providers were notified of results.
- The Director of Nursing reviewed clinical records of current residents with diagnostic test orders from the prior 30 days to validate labs/diagnostic tests were completed as ordered and notified providers of any discrepancies.
- The Assistant Director of Nursing/Staff Development Coordinator began educating licensed nurses on the process to obtain STAT labs from the current lab service.
- The ADON/SDC educated licensed nurses on the process to obtain STAT labs from the current lab service.
- The Staff Development Coordinator began competency validation for licensed nurses on the process for obtaining routine and STAT labs.
- Step-by-step instructions for obtaining labs through the lab website (including STATs) were placed in the front of each lab binder.
- Licensed nurse education on the lab process, provider notification, and documentation was completed for nurses (with sign-in sheets and voice/text education reports used to validate completion).
- An ad hoc QAPI was completed with the Medical Director, Administrator, Director of Nursing, and additional IDT members addressing adherence to policy/process for change in condition, following provider orders, obtaining STAT labs, reviewing diagnostic results, and notifying providers; discussion included provider access to the EMR and ability to view lab/diagnostic results.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple medical conditions experienced a change of condition for which a physician ordered a urinalysis. Review of the electronic record showed no urinalysis results for the period reviewed, despite the order and concurrent initiation of antibiotics. The ADON and DON both confirmed they could not locate the lab results in the EHR and acknowledged that staff should have obtained the specimen or documented any inability to do so. The ADM stated her expectation that clinical staff follow physician orders and document unsuccessful attempts, noting that failure to obtain ordered labs can prevent the physician from addressing potential health issues.
Failure to promptly notify the physician of abnormal lab results occurred for a resident with DM, dysphagia, and hypokalemia who was receiving potassium chloride and spironolactone. A CMP showed elevated K+, BUN, creatinine, and reduced eGFR, but nursing documentation did not show physician notification. The resident later developed increased confusion and a critically high K+ level, and the physician was then notified and ordered transfer to the ER.
Failure to Obtain Ordered UA with C&S: A resident with an indwelling foley catheter and a history of UTI had hematuria noted in the catheter, and the MD ordered a UA with C&S to rule out UTI. Record review and staff interviews showed the specimen was not collected as ordered and the lab was not notified through the lab software, despite the facility’s process requiring the nurse to obtain the specimen and arrange lab pick-up.
Two residents with ESRD, heart failure, acute kidney failure, and type II DM had multiple critical lab values (elevated creatinine and BUN) that were reported by the lab to nursing staff but were not documented as promptly communicated to a provider, and there was no documentation that an RN supervisor assessment was completed as required by policy. Nursing notes lacked entries showing provider notification, times of contact, or new orders at the time critical results were received or later reviewed, and provider documentation of these critical values occurred one or more days after the lab reports. An RN reported signing off lab results as reviewed in the EHR to clear alerts, not realizing only providers should do so, and could not recall specific notifications made, while leadership interviews confirmed expectations for immediate provider notification, RN supervisor follow-up assessment, and complete documentation that were not met in these cases.
A resident with complex cardiac and respiratory conditions had diuretics discontinued by cardiology and a BNP test ordered. The resulting BNP level was critically elevated and flagged as "High High." An LPN received the result, sent it to the physician via secure messaging, did not obtain any orders, was unsure if a phone call was successfully made, and did not notify the cardiologist. The physician later stated he did not see the message until the next morning, did not receive a call from the facility, and did not issue orders. Leadership and other nursing staff reported that critical labs are expected to be called directly to the physician, consistent with the facility’s change-in-condition policy, but no separate lab policy was produced.
A resident with a history of stroke and communication/swallowing difficulties experienced a change in respiratory condition, prompting a physician to order blood work and a urinalysis. The UA later showed elevated WBCs and significant gram-negative bacterial growth consistent with a UTI, but there was no documentation that the physician or NP was notified and no orders for UTI treatment were found. The resident was later sent to the hospital for mental status changes and returned with diagnoses including pneumonia and UTI. The DON and physician confirmed the lack of notification, and leadership acknowledged there was no formal policy for notifying practitioners of abnormal UA results, though it was considered standard practice.
Failure to Obtain Ordered Urinalysis and Document Results
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain laboratory services as ordered and to have results available for review for one resident. A male resident with severe cognitive impairment, a history of acute respiratory failure with hypoxia, dysarthria following stroke, and Alzheimer's disease had a physician order for a urinalysis (UA) on 02/25/2026 following a change of condition. Record review from 02/25/2026 through 04/30/2026 showed no UA results in the electronic clinical record. The resident’s medical record also reflected standing orders for periodic blood work, including CBC, CMP, lipid panel, valproic acid level every six months, and Hgb and A1C every three months, but the cited deficiency focused on the missing UA ordered on 02/25/2026. During interviews, the ADON reported she was unable to locate the UA results for the resident and stated that the UA "had to be done" because the physician had ordered antibiotics. She also stated that if staff had been unsuccessful in obtaining a urine sample, this should have been documented. The DON confirmed she could not find the UA results in the EHR and stated that, because the physician ordered the UA, staff should have obtained the lab. The DON noted that staff were aware of the change of condition, contacted the physician, and that antibiotics were ordered and administered while the resident’s vital signs remained within normal limits. The ADM stated her expectation that clinical staff follow physician orders and document if a sample cannot be obtained, and she acknowledged that failure to obtain ordered labs could lead to potential health issues that the physician would not be able to address.
Failure to Notify Physician of Abnormal Potassium Result
Penalty
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.
Failure to Obtain Ordered UA with C&S
Penalty
Summary
The facility failed to ensure a laboratory service was provided as ordered for one resident with an indwelling urinary/foley catheter and diagnoses including neuromuscular dysfunction of the bladder and urinary tract infection. The resident was observed alert and resting in bed with the catheter in place, and stated the catheter had been placed for safety reasons because he could not stand up to go to the restroom on his own and that he often got urinary tract infections. The resident’s record showed that after hematuria was noted in the foley catheter, the physician was notified and ordered a flush and a UA with C&S to rule out UTI. Record review showed the UA with C&S was ordered, but there was no documented evidence that the specimen was collected as ordered. There was also no documentation that the laboratory was notified of the new physician order. During interviews, an LVN verified the process was not followed and confirmed there was no order placed in the laboratory software for the UA with C&S. The DON stated the licensed nurse should have collected the urine specimen right away, placed it in the specimen refrigerator, and notified the laboratory for pick up, but this was not done.
Failure to Promptly Report and Document Critical Lab Results and RN Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that abnormal and critical laboratory results were promptly reported to providers and followed by an RN supervisor assessment, as required by facility policy. For one resident with end stage renal disease, dependence on hemodialysis, and type II diabetes mellitus, lab work showed a critically high creatinine level of 4.24, reported to the facility in the evening and later reviewed by an RN the following morning. Nursing notes from the date of the lab and the following day did not document that the critical creatinine value was reported to a provider or that an RN supervisor assessed the resident. A provider note from that day did not reference the critical value or any notification, and the provider did not document review of the critical result until two days later. For another resident with heart failure, acute kidney failure, and type II diabetes mellitus, multiple critically high BUN levels were reported over several dates, but there was no documentation that these critical values were promptly communicated to a provider or that an RN supervisor assessment occurred at the time of each result. A critically high BUN of 73 was reported to an RN, but there were no nursing notes for that day and no documentation of provider notification when the result was received or when later reviewed by another RN; the provider did not document review of this lab until two days later. Subsequent critical BUN values of 70, 80, and 75 were each reported to nursing staff and later reviewed by the same RN, yet nursing notes over the corresponding periods did not show timely provider notification or RN supervisor assessment, and provider documentation of these critical values occurred one day later in each instance. Interviews further clarified the actions and inactions contributing to the deficiency. The RN who reviewed many of the critical results stated she was aware of the critical values and believed she had reported them but could not recall to whom, at what time, or whether new orders were obtained, and she was unaware that policy required an RN supervisor assessment to accompany abnormal lab reporting. She also reported that she had been signing off lab results as reviewed in the electronic record to clear them from her homepage, not realizing that only providers should sign off results under the results tab. The Medical Director stated that RNs receiving critical values should immediately notify a provider and document the provider’s name, time of notification, and any new orders, and that only providers should sign off lab work as reviewed. The DON stated that the RNs involved should have ensured immediate provider notification and complete documentation of the notification details for the critical lab results, and acknowledged uncertainty about who should sign off lab work as reviewed and about the specifics of the abnormal lab and physician notification policies.
Failure to Timely Notify Physician of Critical BNP Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a physician of a critical laboratory value for one resident. The resident was admitted with multiple diagnoses including acute on chronic systolic congestive heart failure, COPD, chronic respiratory failure with hypoxia, peripheral vascular disease, obesity class 2, difficulty walking, anxiety, major depressive disorder, osteoarthritis, hypo-osmolality, and hyponatremia. On 4/3/26, cardiology discontinued the resident’s Lasix and Bumex and ordered a complete metabolic panel and BNP test, with instructions for an office follow-up in one week. The BNP result, received by the facility’s lab on 4/9/26 at 9:06 AM, was 761, flagged as a “High High” (HH) critical value, with a normal range of 1–100. A progress note documented that late on 4/9/26, an LPN notified the physician via a secure messaging application. In interview, the LPN stated she received the lab value while on break, sent a secure message to the physician after seeing he was active on the application, did not receive any orders in response, and was unsure whether she successfully attempted a phone call; she also did not notify the cardiologist who ordered the test. The physician reported he received the critical lab notification via secure messaging at 11:24 PM on 4/9/26 but did not see the lab until the next morning and did not respond with any orders, and he stated he did not receive a call from the facility about the critical lab. The regional clinical nurse and DON both stated that critical labs should always be called to the physician, and other LPNs described their usual practice as immediately calling, faxing, and/or using secure messaging for critical labs. The facility’s “Change in Condition” policy required notifying the attending or on-call physician when there is a need to significantly alter medical treatment or a significant change in condition; a specific lab policy was requested but not provided.
Failure to Notify Practitioner of Abnormal Urinalysis Result
Penalty
Summary
The deficiency involves the facility’s failure to notify the ordering practitioner of an abnormal urinalysis result for one resident. The resident was admitted with a history of stroke, resulting in weakness or paralysis on one side of the body, and had difficulty swallowing and speaking. An Interact change-of-condition form documented a change in the resident’s respiratory condition, and the physician ordered blood work and a urinalysis. The urinalysis report later showed elevated white blood cells and more than 100,000 CFU/ml of gram-negative bacteria, indicating a positive result for a urinary tract infection. However, there was no documentation that the physician or nurse practitioner was notified of these abnormal results, and there were no orders showing that the resident was treated for a UTI at that time. Subsequently, the resident was transferred to the hospital for changes in mental status and later returned with diagnoses of pneumonia and UTI. During interviews, the DON confirmed that the urinalysis results were positive for a UTI and acknowledged there was no documentation of physician notification or antibiotic treatment. The physician also confirmed they had not been notified of the abnormal urinalysis results and stated that, although there were no other signs of a UTI besides the urinalysis, they should have been informed. The NHA and DON reported that the facility did not have a specific policy for notifying a physician or extender of an abnormal urinalysis result, but considered such notification to be standard practice.
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