The failure occurred at South Creek Post Acute in November 2025, when Staff D, a medical doctor, ordered CBC and BMP blood work for Resident 1 on November 2. The weekend supervisor attempted the blood draw but was unsuccessful, documenting the failed attempt in the medical record.
Staff D said he wanted the blood drawn the next day, November 3, and gave a verbal order for the lab work. The physician told state inspectors the order was given on a Sunday, and staff should have communicated with him if they continued having problems obtaining the blood sample.
"He did not know why the labs were not obtained," inspectors wrote after interviewing the doctor on December 23.
The blood was never drawn on November 3 or November 4. The resident was sent to the hospital days later.
Staff D told inspectors that if the CBC and BMP results had been obtained as planned, "the resident may have been transferred out of the facility earlier, or given a sodium supplement, depending on the results of the blood labs."
Staff B, the facility's Director of Nursing, confirmed during a December 29 interview that Resident 1 had orders for the blood work dating to November 2. After reviewing the electronic medical record, she could not find any lab results.
The nursing director acknowledged seeing the November 2 progress note documenting the unsuccessful blood draw. She said the physician should have been notified of the failed attempt, and orders should have been moved in the electronic system to prevent them from expiring.
Staff B reviewed the medication administration record and confirmed the CBC and BMP labs were not obtained on November 2, November 3, or November 4.
The inspection report does not specify what medical condition prompted the original lab orders or detail the resident's ultimate hospital stay. CBC tests measure different types of blood cells and can detect infections, anemia, and blood disorders. BMP tests check electrolyte levels, kidney function, and blood sugar.
The facility's failure to follow through on the physician's orders violated Washington state regulations requiring nursing homes to ensure physician orders are carried out promptly and accurately.
State inspectors classified the violation as causing "actual harm" to the resident, indicating the delayed lab work had measurable negative consequences for the patient's health or treatment.
The case illustrates a breakdown in communication between medical staff and nursing personnel. The doctor gave clear instructions for blood work after the initial failed attempt, but those orders never reached completion despite multiple days passing.
Staff D emphasized to inspectors that nursing staff should have contacted him on Sunday when they continued having difficulty obtaining the blood sample. The physician's expectation that staff would communicate obstacles suggests standard protocols were not followed.
The nursing director's acknowledgment that physician notification procedures were not followed points to systemic gaps in the facility's care coordination processes.
For Resident 1, the consequences extended beyond missed lab results. The delayed blood work potentially postponed necessary medical interventions, whether that meant earlier hospital transfer for more intensive monitoring or immediate sodium supplementation based on the test results.
The physician's statement that treatment decisions depended on the lab findings underscores how the nursing staff's inaction created a cascade of delayed care decisions.
The inspection occurred in late December 2025 as part of a complaint investigation, suggesting family members or staff reported concerns about the facility's care practices to state regulators.
South Creek Post Acute's failure to complete ordered blood work represents a fundamental breakdown in basic nursing home operations, where physician orders form the foundation of resident care plans and must be executed without delay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Creek Post Acute from 2025-12-29 including all violations, facility responses, and corrective action plans.