§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
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Observations:
Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident R1).
Findings include:
Review of facility policy "Physician/Provider Orders policy", dated 8/1/2025, indicated the Charge Nurse shall transcribe and review all physician/provider orders. A unit secretary, with demonstrated competence, and when available, may transcribe orders.
Review of Resident R1 admission record indicated she was admitted 9/19/25.
Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 9/25/25, indicated she had diagnoses that included malignant neoplasm of the brain, diabetes mellitus (chronic disorder characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin) , and hypothyroidism (condition when the thyroid gland does not produce enough thyroid hormone).
Review of Resident R1's physician order dated 9/19/25, indicated to acquire a CBC (Complete Blood Count - a blood test that measures the amounts and sizes of various blood components, including: red blood cells, white blood cells, hemoglobin, platelets), CMP (a blood test that measures various substances in your blood to assess your overall health. Includes tests for: kidney function, liver function, blood sugar levels, electrolyte and fluid balance).
Further review of Resident R1's physician order dated 9/21/25, indicated to acquire a CBC CMP on Monday 9/22/25.
There was no documented evidence in Resident 1's clinical record that staff obtained the bloodwork on 9/19/25, and 9/21/25, as ordered by the physician.
During an interview on 11/6/25, at 12:02 p.m., the Director of Nursing (DON) confirmed that there was no documented evidence in the clinical record that the facility staff obtained the bloodwork for Resident R1 on 9/19/25, and 9/21/25, as ordered by the physician.
During an interview on 11/6/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and DON confirmed that the facility failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident R1).
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
| | Plan of Correction - To be completed: 11/17/2025
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1. Resident R1 discharged from the facility on 10/7/2025
2. Current Residents with Lab orders have had their blood draws completed timely per order.
3. Current Nurses have been re-educated, by the DON/designee, on the policy Physician/Provider Orders Policy and specifically to ensure labs are drawn timely per order and if lab is not drawn to indicate reason in progress note.
4. DON/designee will audit labs 2x/weekly for 3 months to ensure residents have their labs drawn timely per order.
5. Results of the audits will be reviewed by the QAPI committee x 4 months and then as directed by the committee.
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