This regulation requires nursing facilities to file laboratory reports in each resident's clinical record, ensuring reports are dated and include the name and address of the testing laboratory. Surveyors will cite deficiencies if reports are missing from the record, undated, or lack the testing laboratory's identifying information. This is a medical records documentation requirement applicable to the facility's clinical recordkeeping practices.
View official sourceF775 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.50(a)(2) The facility must— (iv) File in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory. PROCEDURES Review the resident’s clinical record to determine laboratory reports are included and that the reports are dated and contain the name and address of the testing laboratory. If there are other medical record documentation concerns, refer to §483.70(h) - Medical Records. KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F775, the surveyor’s investigation will generally show that the facility failed to do any one or more of the following: • Have laboratory reports filed in the resident’s clinical record; OR • Laboratory reports were not dated; OR • Laboratory reports did not contain the name and address of the testing laboratory.