Delayed Notification of Lab Results Leads to Treatment Delay
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results for a resident, leading to a delay in treatment. The resident, who was admitted with dementia and chronic kidney disease, experienced increased diarrhea and nausea. A physician ordered laboratory tests, including a CBC, CMP, and MAG, which were collected and reported back to the facility. However, there was no documented evidence that the physician received or acted upon these results for approximately 24 hours. The laboratory results indicated significant dehydration, with elevated BUN and creatinine levels, and a decreased potassium level. Despite these findings, the physician's order for a midline catheter insertion and supplemental fluids was not initiated until approximately 30 hours after the laboratory results were reported. The resident received additional fluids and continuous IV treatment, but these interventions were delayed by more than 40 hours after the laboratory report indicated dehydration. The Director of Nursing confirmed the delay in implementing interventions and treatment to address the resident's dehydration. The DON acknowledged that it is the facility's responsibility to ensure the physician is promptly provided with laboratory results. The report highlights the facility's failure to adhere to its policies and procedures for notifying practitioners of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
Step 1 Resident #1 labs were followed up on 1/10/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of labs completed for the last 2 weeks to ensure abnormal lab studies were followed up with the physician in a timely manner. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on following up with abnormal lab studies with physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for labs per week for 4 weeks, then monthly for 2 months to ensure labs followed up with physician in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.