Resident T's blood work on October 8 revealed a creatinine level of 2.17, more than double her normal baseline of less than 1.0. The 67-year-old woman with schizophrenia, heart failure and high blood pressure had no history of chronic kidney disease.
When the nurse practitioner saw her two days later, he immediately ordered a urinalysis with culture and sensitivity testing. Elevated creatinine can signal acute kidney injury, a sudden episode of kidney failure that causes waste products to build up in the blood and affects the brain, heart and lungs.
The facility sent her urine sample to a specialty laboratory. But that lab only tested for infections, not the comprehensive urinalysis the doctor had ordered.
Six days later, on October 16, nursing staff received results showing no disease-causing organisms in Resident T's urine. They notified the nurse practitioner, who gave no new orders. Nobody realized the wrong test had been performed.
The mix-up remained hidden until federal inspectors arrived at Celebrate Senior Living of Fort Wayne on November 17. During their review of Resident T's medical records, they discovered the laboratory error.
Director of Nursing told inspectors on November 18 that only a culture and sensitivity test had been completed, not the urinalysis the doctor ordered. She explained the specialty lab could detect pathogens in urine but didn't process urinalysis tests.
The nurse practitioner confirmed to inspectors that he had ordered a urinalysis specifically to investigate the cause of Resident T's abnormal kidney function. He said he understood from the laboratory that urinalysis would be completed along with pathogen detection.
Acute kidney injury requires prompt diagnosis and treatment. According to medical literature, urinalysis is a critical test used to find signs of kidney disease and investigate potential causes of kidney failure. The test can reveal whether medications, direct kidney damage or urinary tract blockages are responsible for elevated creatinine levels.
Resident T had been taking blood pressure and diuretic medications that put her at risk for fluid balance problems. Her care plan specifically called for obtaining and monitoring lab work as ordered by physicians.
The facility's own policy required nursing staff to ensure timely collection of specimens and follow providers' orders within their scope of practice. Laboratory services were to be obtained through licensed laboratories upon orders from medical providers.
But the policy didn't prevent staff from sending Resident T's sample to a lab that couldn't perform the test her doctor had ordered. The specialty laboratory processed what it could do rather than what the physician needed.
When the nurse practitioner received results showing no infection, he had no way of knowing the underlying question about her kidney function remained unanswered. The urinalysis that might have revealed the cause of her elevated creatinine was never performed.
Federal inspectors found the facility failed to provide appropriate treatment according to physician orders. They cited minimal harm or potential for actual harm to Resident T.
The inspection was conducted in response to a complaint filed with state health officials. Inspectors reviewed records for three residents and found the laboratory error affected one of them.
Resident T's case illustrates how communication breakdowns between nursing homes and laboratories can delay critical medical care. When her creatinine level jumped to more than twice normal, her doctor needed specific information that only a urinalysis could provide.
Instead, she received a test that answered a different medical question entirely. The mix-up left her physician without the diagnostic information needed to determine why her kidney function had suddenly declined.
Six weeks after the wrong test was performed, inspectors discovered the error during their complaint investigation. By then, Resident T had been living with undiagnosed kidney problems for more than a month while her doctor remained unaware that his ordered test was never completed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Celebrate Senior Living of Fort Wayne from 2025-11-19 including all violations, facility responses, and corrective action plans.
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