The October 2023 incident at Four Seasons Healthcare & Wellness Center revealed how communication breakdowns can delay critical medical care. Federal inspectors found that staff failed to ensure a phlebotomist arrived to draw blood samples despite explicit physician orders requiring results within four hours.
The trouble began when Resident 1 developed blood in their stool. The attending physician immediately ordered STAT hemoglobin and hematocrit tests to determine if the resident was experiencing dangerous blood loss. These urgent lab orders require facilities to obtain results within four hours to guide immediate treatment decisions.
But the phlebotomist never showed up.
Progress notes from 8:46 a.m. on October 4, 2023, documented that staff had notified the doctor that "phlebotomist was still pending" for the STAT lab order. The physician had already told staff that the resident would not need a blood transfusion if hemoglobin levels stayed above 7 grams per deciliter, but without the test results, no one could make that determination.
Meanwhile, Family Member 2 grew increasingly concerned about the delays. Hospital transfer records show the family member "persistently requested to send out Resident 1 to the GACH" starting at 10:05 a.m. The family's insistence ultimately forced the facility's hand.
By 2:44 p.m., more than six hours after the original STAT order, Resident 1 was finally transferred to the General Acute Care Hospital "per Resident 1's request." The transfer documentation noted the episode of blood in stool and confirmed that the doctor had been made aware and ordered the urgent blood work that still hadn't been collected.
The lab results eventually came back that evening, but only after the resident had already been hospitalized. At 9:19 p.m., Lab 1 reported that "Resident 1 was in the hospital." A second result at 11:01 p.m. confirmed the resident tested positive for occult blood, validating the original concerns about internal bleeding.
During interviews with federal inspectors in September 2025, Director of Nursing acknowledged multiple system failures. She confirmed that Lab 1's phlebotomist "did not come on 10/4/2023" and admitted there was no documentation showing nurses had followed up to get a timeframe for when the lab technician would arrive.
"When MDs order STAT labs it is to ensure the results are done within four hours," the nursing director told inspectors. She explained that when STAT labs are ordered, "the nurses need to call the lab and get a timeframe and should then follow up until the labs have been collected."
The nursing director acknowledged that "the night nurse should have called Lab 1 but not sure if Lab 1 gave the nurse a timeframe of when they were coming to the facility as there was no documentation."
She also confirmed that facility records showed no physician order for the repeat hemoglobin and hematocrit tests the doctor had requested on October 4. This documentation gap meant staff had no written record of the physician's specific instructions about blood transfusion thresholds.
The facility's own policies require staff to call STAT lab orders directly to laboratory customer service and identify them as urgent. The policy states that "all attempts will be made to expedite the turnaround time for lab test ordered as STAT."
But those attempts weren't documented in this case.
The nursing director conceded the obvious conclusion: "If STAT labs are not done as ordered by MD there is a potential for a delay in care."
That delay stretched across an entire day, from the morning when bloody stool was first observed until evening when the resident was finally in a hospital bed. The original physician order calling for four-hour turnaround became a 12-hour odyssey that ended only because family members refused to accept the facility's inaction.
The case illustrates how seemingly simple communication failures can cascade into serious care delays. A missing phone call to confirm the phlebotomist's arrival time. No follow-up when the lab technician failed to appear. No documentation of attempts to expedite the urgent blood work.
Federal inspectors classified the violation as causing minimal harm to few residents, but the incident exposed systemic problems with how Four Seasons Healthcare handles urgent medical orders. The resident's bloody stool required immediate assessment to rule out dangerous blood loss, yet the facility's response left family members as the primary advocates pushing for appropriate medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Healthcare & Wellness Center, Lp from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Four Seasons Healthcare & Wellness Center, Lp
- Browse all CA nursing home inspections