The resident's physician suspected the symptoms stemmed from medication toxicity or metabolic problems. On August 7, the doctor ordered five different blood tests and started IV fluids for dehydration. The plan was clear: get the lab work done to determine what was making the patient sick.
But the facility didn't draw the blood for 18 days.
Federal inspectors found the delay placed the resident at risk of clinical complications, unstable medical conditions and delayed recovery. The resident had been admitted with three serious conditions requiring careful monitoring — diabetes, which affects blood sugar control, bipolar disorder marked by extreme mood swings, and dementia.
When the doctor's notes from August 7 described the resident's nausea, vomiting and excessive sleepiness, the physician immediately suspected either medication or metabolic causes. The treatment plan called for laboratory tests including a CMP to monitor electrolyte balance, a CBC blood count, TSH for thyroid function, Hgb A1C for diabetes management, and a valproic acid level to check anti-seizure medication in the blood.
The doctor also ordered IV fluids for 48 hours to combat dehydration from the vomiting.
By August 19, twelve days after the original order, the physician noted in the medical record that labs were still pending. The doctor held the resident's Depakote medication while waiting for the blood work results.
The facility finally drew blood on August 25 — 18 days after the doctor's order. Results for the CMP, CBC and TSH came back that same day. The valproic acid level wasn't completed until September 4, nearly a month after it was ordered.
The Hgb A1C test for diabetes monitoring was never done at all.
Staff A, the facility's Resident Care Manager and Licensed Practical Nurse, discovered the missing lab work during the inspection on September 17. When contacted by inspectors at 2:33 PM, Staff A reviewed the resident's electronic medication administration record and called the facility laboratory to obtain all results.
Staff A could not locate any Hgb A1C result and confirmed the timeline of delays: the CMP, CBC and TSH weren't collected until August 25, and the valproic acid level was completed on September 4.
The resident had experienced symptoms for weeks while waiting for tests that should have been drawn immediately. Nausea and vomiting in a diabetic patient can signal dangerous blood sugar swings or medication toxicity. Excessive sleepiness combined with these symptoms required urgent evaluation.
The facility's Director of Nursing, Staff B, acknowledged the failure when questioned by inspectors at 4:00 PM on September 17. Staff B said when medical providers order labs to be drawn, they expect them to be completed timely.
That expectation wasn't met for this resident, who continued suffering symptoms while critical diagnostic information remained unknown. The doctor had suspected medication or metabolic causes for the resident's condition but couldn't adjust treatment without lab results.
For a resident with diabetes, bipolar disorder and dementia, delayed lab work compounds existing vulnerabilities. Diabetic patients require regular monitoring to prevent life-threatening complications. Psychiatric medications need blood level checks to ensure they're not reaching toxic levels. Dementia patients can't advocate for themselves when feeling sick.
The inspection found Olympic View Post Acute failed to provide timely, quality laboratory services to meet residents' needs. The facility was cited for violating state regulations requiring prompt completion of ordered tests.
The resident's case illustrates how administrative failures translate into human suffering. While the facility delayed basic blood draws, a vulnerable patient endured weeks of nausea, vomiting and dangerous sleepiness without knowing the cause or receiving appropriate treatment adjustments.
Federal inspectors determined the violation caused minimal harm or potential for actual harm. But for the resident who waited 18 days for answers while feeling sick, the impact was immediate and prolonged.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Olympic View Post Acute from 2025-09-17 including all violations, facility responses, and corrective action plans.