Delayed Lab Draws and Results for Stool, STAT Infection Workups, and PT/INR Monitoring
Summary
The deficiency involves the facility’s failure to ensure timely laboratory services and results for four residents after physician orders were obtained. For one resident with chronic kidney disease, Parkinson’s disease, and dementia, a change in condition was documented when loose, mucus-like stool with odor was noted. A stool sample for C. difficile testing was ordered and picked up by the contracted lab, but the result was not returned within the expected timeframe. Nursing notes show repeated calls to the lab with no answer, eventual notification that the specimen was no longer viable, and a lack of prior notification to the facility about this issue. A subsequent STAT C. difficile order was placed, the specimen was picked up, and staff again made multiple calls to the lab before the result was finally received, creating a prolonged delay between the initial change in condition and receipt of the test result. Another resident with type 2 diabetes and benign prostatic hyperplasia experienced a change in condition with complaints of not feeling well, dark urine, and hematuria. The physician ordered STAT CBC, BMP, and UA with C&S, and also ordered staff to follow up with the lab if the blood draw was not completed or to call for STAT results. Progress notes document that staff called the lab, faxed the STAT order, and that no one came initially to draw the blood. The urine sample was not collected and picked up until the following day, and by several days later the UA C&S results were still pending. The physician, finding no lab results available during assessment, ordered the resident to be sent to the ED, where a UTI was diagnosed and antibiotic therapy initiated. A third resident with spastic quadriplegic cerebral palsy and communication disorders was on warfarin and required regular PT/INR monitoring. Orders and progress notes show multiple scheduled and STAT PT/INR tests in December, but there were gaps in documentation of draws, delays in obtaining results, and repeated unsuccessful attempts to contact the lab. Staff documented that PT/INR was drawn but results were still “awaiting,” that phlebotomists came at night to draw STAT labs, that calls to the lab went unanswered or the phone line cut out, and that additional STAT PT/INR orders had to be placed due to missing or delayed results. Nurses and the DON reported that since switching to a new lab company, results were faxed rather than integrated into the electronic chart and were taking longer, with no backup lab available other than sending residents to the ED. A fourth resident with atrial fibrillation and congestive heart failure, also on warfarin, had weekly PT/INR testing and dosing managed through a coumadin clinic. Progress notes show a change in condition related to missed warfarin doses and a STAT PT/INR ordered and called to the lab. A phlebotomist drew the STAT PT/INR in the early morning, but nurses documented multiple follow-up calls to the lab without results, confusion over requisitions that did not include PT/INR, and the need to create a new requisition and redraw blood. Hospital anticoagulation communication records later reflected missed warfarin doses on several days, which the DON attributed to the lab’s failure to complete the PT/INR draw and the resulting lack of current dosing orders. Throughout these events, the DON and Administrator confirmed that the lab was expected, per contract and facility practice, to prioritize STAT orders and return results promptly, but that there were repeated delays in draws and reporting for these four residents. The facility’s own policy stated that the lab or testing source would report test results to the facility and that concerns about handling or reporting of results should be communicated to the DON or Medical Director, without delaying clinically appropriate management. Interviews with multiple nurses and the DON confirmed that staff repeatedly attempted to follow up with the lab by phone and fax, that results were not received within the expected 4–8 hours for STAT draws and 24–72 hours for routine tests, and that there was no alternative contracted lab at the time. The contracted lab’s representative described a process in which orders are received by email or fax, confirmed with the facility, and prioritized for STAT processing, but the documented experiences for these four residents show that orders, draws, and results were not consistently handled within those expectations, leading to the cited deficiency in timely laboratory services and test results.
Penalty
Resources
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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 with overactive bladder and complaints of dysuria had an order for a one-time UA C&S, along with care plan interventions for labs per orders and monitoring for UTI. Staff did not attempt to obtain the urine specimen until five days after the order, when an LPN’s initial straight cath attempt was unsuccessful due to positioning and a subsequent attempt was refused by the resident, who requested a bedpan instead. There was no documentation of earlier collection attempts, no evidence that the provider was notified of the refusal, and no record that the ordered UA C&S was ever completed, despite facility policy requiring timely completion of ordered lab services.
Delayed laboratory testing for suspected UTI: An LPN documented unusual behaviors in a resident with Huntington's disease and severe cognitive impairment and contacted the CNP for UTI evaluation, but no urine collection or lab orders were placed in the record at that time. Urine was collected several days later, the specimen reached the lab after additional delay, and UA and culture results later showed E. coli; an RN later contacted the CNP about the results and antibiotic orders were entered.
A resident with multiple complex medical conditions did not receive ordered urine analysis with culture and sensitivity tests. The facility failed to collect the required laboratory samples and did not document the missed tests or notify the prescribing provider. The DON confirmed the omission and lack of documentation.
A resident with multiple serious health conditions experienced a critically low potassium level, prompting a physician to order immediate potassium administration and additional lab tests. Although the RN relayed the orders to an LPN, only a basic metabolic panel was completed, and the required comprehensive metabolic panel and magnesium tests were not performed. The DON confirmed the orders were not entered into the medical record, and staff interviews revealed a breakdown in communication and follow-through.
The facility did not ensure that physician-ordered laboratory tests were completed for two residents with complex medical conditions. Despite orders for multiple labs, only some were completed, and several were not obtained or on file, as confirmed by the DON. This failure was contrary to facility policy requiring staff to process and arrange for all ordered diagnostic testing.
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 Obtain Ordered UA C&S for Resident with Dysuria
Penalty
Summary
The facility failed to ensure that a urinalysis with culture and sensitivity (UA C&S) was obtained as ordered for a resident with risk factors for urinary tract infection (UTI). The resident was admitted with diagnoses including spinal stenosis and radiculopathy and had a care plan indicating risk for bladder incontinence, skin breakdown, and UTI due to overactive bladder, with goals to minimize risk of septicemia through prompt recognition and treatment of UTI symptoms. An order dated 10/17/25 directed that a UA C&S be obtained one time for dysuria. A subsequent care plan dated 10/20/25 documented that the resident was at risk for UTI due to complaints of dysuria, with interventions including encouraging fluids, obtaining labs per orders, and taking vitals as ordered or per facility protocol. Nursing documentation showed that on 10/22/25 at 10:00 A.M., an LPN attempted to obtain a urine specimen via straight catheterization but was unable to do so due to the resident’s positioning, and planned to attempt again after repositioning. At 10:30 A.M. the same day, after repositioning, the resident yelled that she did not want to be straight cathed and requested to use a bedpan for the sample, then refused. There was no evidence in the medical record of any attempts to collect the urine sample prior to 10/22/25, no documentation that the provider was notified of the resident’s refusal, and no evidence that the ordered urine test was ever obtained. The PA who ordered the UA C&S confirmed there were no results in the record and stated he would have expected the sample to be collected as quickly as possible. The DON confirmed that the order was given on 10/17/25 and that collection was not attempted until five days later, contrary to the facility’s laboratory services policy requiring labs to be completed and results provided within normal timeframes for appropriate intervention.
Plan Of Correction
1. Resident #8 had a urinalysis collected on 10/23/26 by Ohio Health Hospital and received treatment as ordered by the physician. 2. Like Residents are identified as residents who have received orders for a urinalysis. An audit will be completed by the Director of Nursing or designee for residents who have received an order for a urinalysis in the past 30 days utilizing the Laboratory Services Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Laboratory Services Policy to ensure urinalysis tests are obtained and results are provided within timeframes normal for appropriate intervention. This education will be completed on or before 5/13/26. 4. Utilizing the Laboratory Services Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of all urinalysis ordered within the last 7 days, weekly for four weeks beginning 5/14/26 to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. Noncompliance noted during the audits will be corrected with urinalysis obtained, physician notified of results and physician orders were carried out as appropriate. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the
Delayed Laboratory Testing for Suspected UTI
Penalty
Summary
The facility failed to execute timely laboratory orders for one resident with Huntington's disease, overactive bladder, spinal stenosis of the lumbar region, and severe cognitive impairment. On 12/19/25, an LPN documented unusual behaviors, including cleaning walls with tissue paper and attempting to put lotion on a sandwich, and contacted the CNP, who gave orders to check for a UTI. However, the medical record did not contain an order for urine collection, urinalysis, or culture and sensitivity/susceptibility testing at that time. Urine was not collected until 12/25/25, and the specimen was not received by the laboratory until 12/26/25. Urinalysis results were reported on 12/26/25, and urine culture and susceptibility results were reported on 12/29/25, showing Escherichia coli. A care conference note later described the resident as having a slight UTI and stated the doctor was aware. On 01/05/26, an RN contacted the CNP regarding the culture and susceptibility results, and later that day physician orders were entered for cephalexin 500 mg twice daily for seven days to treat the UTI. The LPN confirmed the urine sample collection was not timely, and the DON confirmed there were no orders in the medical record for the resident's urine collection, analysis, or culture and sensitivity.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered for one resident. The medical record review showed that the resident, who had diagnoses including morbid obesity, lymphedema, chronic embolism and thrombosis, and hereditary deficiency of clotting factor, was admitted and later transferred to the hospital, where they expired. The resident's care plan included interventions such as laboratory tests as ordered, particularly urine analysis with culture and sensitivity to rule out urinary tract infections. However, there were two separate orders for urine analysis with culture and sensitivity that were not completed as required. Further review of the electronic medical record revealed no results for the ordered urine analyses, and there was no documentation indicating that the prescribing provider was notified about the missed tests. Additionally, the progress notes and the resident's medical record did not contain any information regarding the facility's failure to obtain the ordered laboratory tests. The DON confirmed during an interview that the laboratory tests were not collected as ordered and that there was no documentation of this failure in the medical record.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, and an open wound. The resident had a critically low potassium level identified through laboratory testing, which prompted the physician to order immediate administration of potassium chloride and additional laboratory tests, specifically a comprehensive metabolic panel (CMP) and magnesium level. The orders were communicated by an RN to an LPN, who acknowledged understanding of the instructions. Despite these orders, only a basic metabolic panel (BMP) was completed, and the required CMP and magnesium tests were not performed. The failure was confirmed through closed record review and interviews, with the DON verifying that the orders for the additional blood work were not entered into the medical record. The LPN involved could not recall details about the potassium or the ordered blood work, and the RN confirmed that the orders were relayed but not executed. Facility policies required nurses to transcribe and execute physician orders or ensure a safe hand-off, and to contact laboratory services as needed, but these procedures were not followed in this instance.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory values were completed as ordered by the physician for two out of three residents reviewed. For one resident with multiple diagnoses including dementia, pressure ulcers, diabetes, and cerebral atherosclerosis, a wound care nurse practitioner ordered several labs (CBC, CMP, albumin, prealbumin, transferrin, and hemoglobin A1c). While the CMP was completed, the other ordered labs were not obtained or on file, as confirmed by the Director of Nursing (DON). Another resident with a history of pseudobulbar affect, stroke, depression, Alzheimer's disease, diabetes, hyperlipidemia, hypertension, anxiety, chronic kidney disease, and other cerebrovascular disease also had several labs ordered (CBC, CMP, TSH, A1c, lipid panel, ferritin, B12, and vitamin D) to be collected on a specified lab day. None of these labs were collected or on file, as verified by the DON. The facility's policy required staff to process test requisitions and arrange for testing, but this was not followed for these residents.
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