River Trace Nursing: Lab Results Never Sent to Doctor - NC
River Trace Nursing and Rehabilitation Center collected blood from Resident 130 on October 16, 2024, after receiving a telephone order from the patient's cardiologist for a basic metabolic panel. The facility's medical director reviewed the results five days later. Nobody called the cardiologist's office.
The blood work showed seven values outside normal ranges. The resident's glucose measured 113, above the normal ceiling of 99. Creatinine hit 1.53, well above the 1.00 limit and signaling potential kidney problems for someone already diagnosed with chronic kidney disease. Carbon dioxide dropped to 19, below the normal range of 20-29.
Three blood count measurements also fell short of normal ranges. The resident's red blood cell count, hemoglobin, and hematocrit all registered below acceptable levels, suggesting possible anemia. Iron levels measured just 23, far below the normal range starting at 27.
The cardiologist's office never received the results.
"The office never received the results of Resident 130's BMP," a patient access representative at the cardiology office told inspectors in August 2025. The nurse practitioner who ordered the original test grew concerned enough by late October to order additional blood work through an outside provider. Those results reached the cardiologist the same day they were drawn.
Federal inspectors found a facility where nobody seemed certain who should communicate lab results to ordering physicians. The confusion extended from floor nurses to top administrators.
Assistant Director of Nursing initially told inspectors that "the facility completes the blood drawings and the results should have been reported to the provider that ordered the blood test." When pressed for specifics, she said "the nurse assigned to the hall where the resident lived should have called in the results."
The facility's medical director deflected responsibility entirely. During a telephone interview, he "referred this surveyor back to the Assistant Director of Nursing to see who should have reported the lab results to the ordering provider." He added that he "did not feel the lack of reporting adversely affected this resident."
Director of Nursing admitted she wasn't sure of facility policy, explaining she was new to River Trace. She suggested lab results "would typically be a provider-to-provider conversation."
The administrator also claimed newness as an excuse. She "revealed she was new to the facility and not sure who should have reported the blood draw results to the provider that ordered the labs."
Only the regional nurse consultant offered a clear answer. She told inspectors that "anyone could communicate the results of blood work but typically the unit manager would notify the prescribing provider of the results."
Resident 130 arrived at River Trace with multiple serious cardiac and kidney conditions. The patient's diagnoses included obstructive sleep apnea, chronic kidney disease, chronic atrial fibrillation, and congestive heart failure. For someone with this medical profile, abnormal lab values could signal dangerous changes requiring immediate attention.
The cardiologist's office ordered the blood panel on October 11, 2024. A facility nurse didn't sign off on the order until three days later. The blood draw happened two days after that. Results came back promptly but sat in the facility's system while the medical director reviewed them on October 21.
Meanwhile, the cardiologist waited. When no results arrived, the office ordered new blood work through an outside laboratory on October 30. Those results reached the ordering provider immediately.
The inspection revealed a facility where basic communication protocols had broken down. Multiple staff members acknowledged that lab results should reach ordering physicians, but nobody took responsibility for making it happen.
Federal inspectors attempted several times to reach the nurse practitioner who originally ordered the blood work. Those calls were unsuccessful.
The violation affected one of six residents whose records inspectors reviewed during their August 2025 complaint investigation. The finding resulted in a citation for failing to promptly notify practitioners of laboratory test results, though inspectors classified the harm level as minimal.
For Resident 130, the facility's communication failure meant nearly three weeks passed between the blood draw and the cardiologist's decision to order replacement testing. The abnormal kidney function markers, blood count deficiencies, and elevated glucose levels remained invisible to the specialist managing the patient's complex cardiac care.
The resident's chronic conditions made timely lab communication particularly critical. Atrial fibrillation patients require careful monitoring of blood chemistry to prevent complications. Kidney disease can worsen rapidly without proper oversight. Heart failure patients need regular assessment of their body's fluid and electrolyte balance.
River Trace's medical director saw no problem with the delayed communication. The cardiologist's office, faced with missing results for a high-risk patient, ordered new tests to fill the information gap their original order should have provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Trace Nursing and Rehabilitation Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
River Trace Nursing and Rehabilitation Center in Washington, NC was cited for violations during a health inspection on August 22, 2025.
The facility's medical director reviewed the results five days later.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.