Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure prompt notification of a resident's physician regarding abnormal laboratory test results. Resident R34, who was admitted from a hospital, had a history of high blood pressure, diabetes, and pain. The resident had physician orders for laboratory tests, including a CBC and BMP, on multiple occasions. However, the clinical records did not show any documentation of communication with the physician about the abnormal results from these tests. Specifically, on 9/20/24, the resident's lab results showed out-of-range values for BUN, RBC, HGB, HCT, and MCHC, but there was no record of notifying the physician or obtaining new orders. Further, on 12/4/24, the resident's lab results again showed abnormal values for glucose, BUN, creatinine, and anion gap, yet the clinical record lacked evidence of physician notification. On 12/9/24, the lab results indicated abnormal BUN, anion gap, HGB, and HCT levels. Although a nurse practitioner signed off on the review of these results, the documentation did not include a date to confirm prompt notification. The Director of Nursing confirmed the facility's failure to notify the physician promptly about these abnormal results, as required by the facility's policy and state regulations.
Plan Of Correction
Physician was notified about R34's abnormal laboratory test results. A lookback of 30 days will be conducted to ensure physicians were notified of any abnormal laboratory test results. Licensed nurses will be educated by DON or designee to notify physician of any abnormal laboratory tests in a timely manner, and to verify the date on the results. Audits will be conducted by DON or designee weekly to ensure abnormal lab results are communicated to the physician x4 weeks then monthly x1 months to ensure physicians are notified of abnormal lab results. Results of audits will be reviewed through the QAPI process/meeting.