The failure at Roosevelt Rehabilitation and Healthcare Center left medical staff unable to determine whether the resident's condition had improved or worsened after initial treatment.
On September 6, the resident's physician documented a potassium level of 5.5 — well above the normal range of 3.5 to 5.0. High potassium can cause irregular heartbeats and muscle weakness. The doctor noted the blood sample had likely hemolyzed, meaning red blood cells had burst and contaminated the results.
The physician ordered a repeat Basic Metabolic Panel for September 8 to get accurate readings.
Nobody drew the blood.
Six days later, on September 12, another physician progress note revealed the September 8 lab work had never been completed. The doctor ordered a Comprehensive Metabolic Panel instead, a more extensive blood test to assess the resident's overall health.
That test also went undone.
State inspectors found no evidence in the resident's clinical records that either blood draw was ever completed. The Director of Nursing confirmed during a September 12 interview that staff had failed to obtain both lab orders.
The oversight meant physicians couldn't monitor whether the resident's potassium levels had returned to safe ranges or required immediate intervention. Elevated potassium, known medically as hyperkalemia, can be life-threatening if left untreated.
Blood draws are routine procedures in nursing homes, typically performed by certified nursing assistants or licensed practical nurses. The tests help physicians track medication effectiveness, monitor chronic conditions, and detect new health problems.
Roosevelt Rehabilitation operates on Bustleton Avenue in Northeast Philadelphia. The facility has faced previous regulatory scrutiny, though the scope of this complaint inspection was limited to laboratory services.
The hemolyzed blood sample that triggered the initial concern occurs when red blood cells break down during collection or processing. This can happen if blood is drawn too forcefully, shaken too vigorously, or stored improperly. The breakdown releases cellular contents into the plasma, making test results unreliable.
For potassium specifically, hemolysis can create falsely elevated readings. That's why the September 6 physician suspected the 5.5 result might not reflect the resident's true levels and ordered the repeat test.
But without the follow-up labs, medical staff had no way to know if the resident's potassium was actually dangerously high or if the initial reading was simply a laboratory error.
The inspection found Roosevelt Rehabilitation failed to maintain proper agreements with approved laboratories to ensure timely test completion. Federal regulations require nursing homes to either provide on-site lab services or contract with certified laboratories for resident testing needs.
Pennsylvania state regulations also mandate that nursing facilities maintain adequate clinical records and provide appropriate nursing services, including ensuring physician orders are carried out promptly.
The violation affected what inspectors classified as "few" residents, though the report details only one specific case. The level of harm was deemed "minimal harm or potential for actual harm."
However, the consequences of missing critical lab work can escalate quickly in elderly residents, who often take multiple medications and have complex medical conditions that require careful monitoring.
The Director of Nursing's admission that staff failed to complete the ordered tests suggests systemic problems with following physician instructions rather than isolated oversights.
Roosevelt Rehabilitation must submit a plan of correction detailing how it will ensure laboratory orders are completed as prescribed. The facility has 14 days from receiving the inspection report to make its response public.
The resident whose potassium levels went unmonitored for days remains at the facility. Whether additional blood work was eventually completed or if the resident experienced any adverse effects from the delayed testing was not documented in the available inspection records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Rehabilitation and Healthcare Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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