Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for a resident, leading to a deficiency in compliance with regulatory requirements. The facility's policy, dated July 26, 2024, mandates that laboratory results must be reported in writing to the resident's attending physician or the facility, with the Director of Nursing Services or charge nurse responsible for notifying the physician of such results. However, in the case of a resident with debilitating cardiorespiratory conditions, the facility did not adhere to this policy. The resident, who was cognitively intact and required assistance for daily care, had physician orders dated September 4, 2024, for a Clostridioides difficile (C-diff) toxin stool test due to frequent watery stools. The laboratory results, dated September 5, 2024, confirmed the presence of the C-difficile toxin, with the sample collected on September 4, 2024. Despite the positive result, there was no documented evidence in the resident's clinical record that the physician was notified or reviewed the abnormal laboratory results. An interview with the Director of Nursing on December 3, 2024, confirmed the lack of documentation regarding the notification of the physician about the abnormal results. This oversight indicates a failure to comply with the facility's policy and regulatory requirements for notifying physicians of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
F0773 Lab Services Physician Order/Notify of Results 1. Resident 2 no longer resides at the facility. 2. A 30 day look back audit was completed of laboratory study orders to ensure that laboratory studies were obtained, results were received and reviewed with the physician. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that laboratory studies were obtained, results were received and reviewed by the physician. The Director of Nursing or designee will complete education with Registered Nurse Supervisors to ensure laboratory studies that are ordered are obtained, results are received and then reviewed with the physician. 4. The Director of Nursing or designee will complete audits to ensure that laboratory studies that are ordered are obtained, results are received and then reviewed by the physician. This audit will be completed weekly times 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.