Medical Suites at Oak Creek failed to secure proper authorization before performing complete blood count tests on Resident 98, who had been readmitted with an abdominal hematoma discovered during a hospital stay, according to a federal inspection completed October 3.
The 98-year-old resident scored 12 out of 15 on a cognitive assessment, indicating moderate impairment. Hospital discharge instructions recommended monitoring the patient's hemoglobin levels due to internal bleeding detected on a CT scan.
Unit Manager 1 told inspectors the resident's power of attorney had emailed requesting lab work based on hospital recommendations. "I reviewed the discharge summary, and it said on the CT scan to follow up with abdominal CT scan if her hemoglobin was less than eight due to the CT scan in the hospital finding an abdominal hematoma," the manager explained.
The unit manager said she consulted the facility's nurse practitioner, who recommended drawing blood every two weeks starting August 18. But when inspectors reviewed the resident's electronic medical record, they found no physician orders authorizing the tests.
Nobody had documented the verbal instruction.
The Director of Nursing scrambled to produce lab results when inspectors asked for them on October 2. Two hours later, she presented records showing complete blood counts had indeed been performed every two weeks since August 18 — all without proper authorization.
Federal regulations require nursing homes to obtain physician orders before conducting laboratory tests to prevent unnecessary procedures and ensure appropriate medical oversight. The facility's own staff acknowledged this requirement during interviews.
"Whoever orders the lab tests are responsible for putting the orders into PCC," Unit Manager 1 told inspectors, referring to the facility's Point Click Care system.
The Director of Nursing confirmed that providers can enter orders directly into the electronic system. "If they do not, then the nurse that speaks to the provider will be responsible for placing these orders in PCC," she said.
But the nurse practitioner who allegedly recommended the testing told inspectors she lacked system access. "I don't have access to put the orders into PCC," she said during a phone interview. "I remember talking to [Unit Manager 1] about having these labs performed every two weeks."
The communication breakdown left the resident receiving medical procedures for nearly seven weeks without proper documentation or oversight. Hospital discharge summaries had recommended monitoring only if hemoglobin dropped below eight, but the facility implemented routine testing without establishing baseline values or parameters.
When pressed about policies governing laboratory services, the Director of Nursing revealed another gap: the facility had no written procedures for handling lab orders.
The inspection occurred following a complaint, though the report does not specify the nature of the original concern. Resident 98 was one of 30 patients reviewed during the investigation.
Federal inspectors classified the violation as having potential for harm, noting it could lead to unnecessary testing of other residents if the practice continued. The facility's failure to maintain proper medical record documentation also violated Medicare and Medicaid participation requirements.
The case illustrates common communication failures in nursing home care, where verbal instructions between staff members can result in unauthorized medical procedures. Without written orders, facilities cannot demonstrate that treatments align with physician recommendations or that appropriate medical oversight exists.
For Resident 98, the unauthorized blood draws occurred during a vulnerable period following hospitalization for internal bleeding. The resident's cognitive impairment meant they likely could not advocate for themselves or question the repeated procedures.
The inspection found the facility's electronic medical record system contained detailed information about the resident's condition and assessment scores, but lacked the fundamental physician orders required to justify ongoing medical interventions.
Medical Suites at Oak Creek must now develop policies for laboratory services and ensure all medical procedures receive proper authorization before implementation. The facility's response to these deficiencies was not included in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medical Suites At Oak Creek (the) from 2025-10-03 including all violations, facility responses, and corrective action plans.
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