Hollywood Premier Healthcare Center failed to obtain a comprehensive metabolic panel for a resident with severe cognitive impairment, failure to thrive, and seizure disorder, according to a federal inspection completed in September.
The physician ordered blood work on August 13 to be completed two days later. The tests never happened.
The resident, admitted to the facility in 2019 and readmitted earlier this year, required complete assistance with eating, toileting, bathing, and personal hygiene. A comprehensive metabolic panel includes 14 blood tests that measure kidney function, liver function, blood sugar, and electrolyte levels.
LVN 3 told inspectors she couldn't find the test results. She also couldn't find any documentation explaining why the blood work wasn't done.
The medical records director confirmed the tests were never performed.
"If Resident 1's CMP was not done, we will not be able to identify what is wrong with the resident," the director of staff development told inspectors.
The facility's own policy requires staff to process test requisitions and arrange for laboratory work based on residents' diagnostic and monitoring needs. Nurses are supposed to determine whether tests were completed as routine screenings, to assess condition changes, or to monitor drug levels.
None of that happened.
Federal inspectors found the violation during a complaint investigation. The failure to provide timely laboratory services violated federal regulations requiring nursing homes to meet residents' medical and diagnostic needs.
The inspection report doesn't explain what prompted the doctor's order for blood work or whether the resident's condition deteriorated without the diagnostic information. For a patient with multiple serious conditions including seizure disorder and failure to thrive, blood chemistry results can reveal kidney problems, medication toxicity, or metabolic imbalances that require immediate treatment.
Comprehensive metabolic panels are among the most basic diagnostic tools in medicine. The tests measure glucose, electrolytes, kidney markers, and liver function. Results help doctors adjust medications, identify infections, and monitor chronic conditions.
The facility has operated under the same name since at least 2019, when the affected resident was first admitted. The resident's readmission date was redacted from the inspection report to protect confidentiality.
Staff interviewed by inspectors offered no explanation for the missed tests. The licensed vocational nurse responsible for following up on the physician's order simply stated she couldn't locate results or documentation.
Federal regulations require nursing homes to provide laboratory services to meet residents' needs. Facilities must ensure physician orders are carried out promptly and results are available for medical decision-making.
The violation received a "minimal harm" rating, the lowest level on the federal scale. But the director of staff development's comment suggests the impact could have been significant. Without blood chemistry results, doctors can't properly manage medications or identify developing complications.
The missed blood work represents a basic failure in the facility's systems for tracking and completing physician orders. The comprehensive metabolic panel should have been routine for a resident with the documented medical conditions.
Hollywood Premier Healthcare Center's policy manual acknowledges the importance of laboratory testing for resident care. The policy reviewed in January specifically outlines staff responsibilities for processing test orders and ensuring completion.
The facility failed to follow its own procedures.
Federal inspectors classified few residents as affected by the violation, suggesting the problem was isolated to this case. But the complete breakdown in following physician orders raises questions about oversight of medical care.
The resident's severe cognitive impairment meant they couldn't advocate for themselves or question why blood wasn't drawn as scheduled. Family members, if involved in care decisions, would have had no way of knowing about the missed tests without reviewing medical records.
For nursing home residents with complex medical conditions, timely laboratory results can mean the difference between stable management and medical crisis. The failure to obtain ordered blood work left both resident and physician without critical diagnostic information for nearly a month before inspectors discovered the problem.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hollywood Premier Healthcare Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Hollywood Premier Healthcare Center
- Browse all CA nursing home inspections