The failure occurred at Woodlands Healthcare Center in June 2025, when Resident 1 declined multiple attempts to draw blood for tests ordered by their physician. The resident's medical conditions — diabetes type 2, chronic kidney disease, and atrial fibrillation — made the blood work critical for monitoring their health status.
Laboratory staff made five separate attempts to collect blood samples between June 21 and June 25. Requisition records show they tried on June 21 at 4:02 p.m., June 23 at 1:02 p.m., June 24 at 12:03 p.m., and twice on June 25 at 9:09 a.m. and 6:04 p.m.
The ordered tests included a basic metabolic panel, complete blood count with differential, iron levels, and an A1C test that measures average blood sugar over two to three months. For a diabetic patient with kidney disease, these tests provide essential information about blood sugar control, kidney function, and overall health status.
Despite the multiple refusals, nursing notes from June 21 through June 25 contained no documentation that the resident had declined the blood draw. No test results appeared in the resident's medical record.
Licensed Vocational Nurse A told inspectors during a July 1 interview that no results existed for the ordered blood tests. The nurse said they couldn't recall why the blood draw wasn't completed but suggested the resident might have refused.
"Possibility resident refused blood work," the nurse stated.
The facility's director of nursing confirmed the blood draw was never completed during a July 1 interview. The director said Resident 1 refused blood draws for several consecutive days when laboratory staff attempted to collect samples, as indicated by the multiple requisitions.
More significantly, the director admitted that licensed staff never informed the primary care physician about the repeated refusals. Nursing staff also failed to document the refusals in the resident's medical record.
"License staff should have informed PCP and documented when Resident 1 refused blood draw for testing," the director told inspectors.
The facility's own policy requires specific documentation when residents refuse treatment. According to the policy titled "Requesting, Refusing and/or Discontinuing Care or Treatment," staff must document the date and time treatment was attempted, the type of care or treatment, the resident's response and stated reasons for refusal, and the name of the person who attempted to provide care.
The policy also mandates that staff record the date and time the practitioner was notified and the practitioner's response. Healthcare practitioners must be notified of treatment refusals "in a time frame determined by the resident's condition and potential serious consequences of the request."
For a diabetic patient with kidney disease and heart rhythm problems, delayed notification could affect critical medical decisions. Blood sugar monitoring through A1C tests helps doctors adjust diabetes medications. Basic metabolic panels track kidney function, which is already compromised in this resident. Complete blood counts can reveal infections or other complications that require immediate attention.
The resident had been admitted to Woodlands Healthcare Center on July 9, 2024, nearly a year before the inspection. Their complex medical conditions required regular monitoring that depends on laboratory results to guide treatment decisions.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, but noted it had the potential to affect Resident 1's medical condition and well-being. The failure violated federal requirements that nursing facilities provide services meeting professional standards of quality.
The case illustrates a breakdown in basic communication protocols between nursing staff and physicians. When residents refuse medical treatments, especially those with serious chronic conditions, doctors need immediate notification to consider alternative approaches or assess whether the refusal indicates changes in the patient's condition or capacity.
Without documentation of the refusals, there's no record of why the resident declined the tests or whether staff attempted to address their concerns. The missing communication left the primary care physician unaware that ordered monitoring wasn't occurring, potentially compromising ongoing medical management.
The facility's director of nursing acknowledged the failures during the inspection, confirming that proper notification and documentation procedures weren't followed despite clear policy requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodlands Healthcare Center from 2025-09-19 including all violations, facility responses, and corrective action plans.