The resident's blood was drawn on September 5, but the facility's physician assistant didn't review the concerning results until September 9. During that four-day gap, the resident's sodium levels, chloride levels, glucose levels, and white blood cell count all measured dangerously high.
Nobody called the medical provider.
The director of nursing acknowledged the breakdown during a December 30 interview with federal inspectors. She confirmed that the lab results showed multiple abnormal values that required immediate physician notification under facility policy.
"Yes the labs should have been called to the provider," the director told inspectors after reviewing the September 5 lab report.
The director explained she normally reviewed all incoming lab results herself but had been on vacation that week in September. Unit managers were supposed to cover her responsibilities during her absence, but the facility had only one unit manager working at the time.
The administrator painted a picture of widespread staffing chaos during the same period. Different nurses were working in the building that week who weren't the facility's typical staff and hadn't worked there for months. She believed more agency nurses than usual were covering shifts, and they weren't the facility's regular agency workers either.
"She explained she thought the facility had more agency nurses working in the building that week who were not the facility's routine agency nurses," the inspection report stated.
The administrator told inspectors she wasn't sure where the communication breakdown occurred or what specifically happened with the resident's lab results that the facility received on September 6.
When the director of nursing was absent, the oversight system for labs and provider notification operated differently. The unit managers were responsible for following up on critical results, but the facility was experiencing a transition in unit management during that exact timeframe.
The administrator confirmed that abnormal lab results should be reported immediately to medical providers when received from the laboratory. The facility's own policy required immediate notification for the types of elevated values found in this resident's blood work.
High sodium levels can indicate dehydration, kidney problems, or other serious medical conditions requiring prompt treatment. Elevated glucose suggests diabetes complications that need immediate management. High white blood cell counts often signal infection or other conditions requiring urgent medical intervention.
The four-day delay meant the resident went from Friday through the following Tuesday without medical providers knowing about potentially dangerous changes in their condition.
The director of nursing had returned from vacation by the time inspectors arrived in December, but the damage from September's staffing breakdown had already been documented. She reviewed the resident's lab results with inspectors and confirmed each abnormal value that should have triggered an immediate call to the physician assistant.
The facility's administrator couldn't explain why multiple layers of backup systems failed simultaneously. Unit managers didn't follow through on lab oversight responsibilities. Temporary nursing staff didn't recognize or act on critical results. The usual agency nurses who might have known the facility's procedures weren't working that week.
Federal inspectors found the facility violated regulations requiring prompt notification of residents' medical providers about significant changes in condition. The violation received a minimal harm designation, meaning inspectors determined the breakdown didn't cause serious injury but created potential for actual harm.
The resident whose labs went unreported for four days remained at Bear Mountain Health during the December inspection. The facility's administrator told inspectors she still wasn't sure exactly what went wrong during that September week when vacation schedules, staffing transitions, and unfamiliar temporary workers converged into a perfect storm of missed medical communications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bear Mountain Health and Rehabilitation from 2025-12-30 including all violations, facility responses, and corrective action plans.