Failure to Communicate Lab Results to Physician
Penalty
Summary
The facility failed to ensure that laboratory results were communicated to the physician for one of three sampled residents. The resident in question had a history of pneumonia and urinary tract infection and was admitted with symptoms including vomiting, decreased appetite, reduced fluid intake, and low urine output. A physician's order was placed for a repeat CBC and CMP, and the blood was collected and results received the same day, with multiple abnormal findings noted. Despite the receipt of these lab results, there was no documentation in the resident's medical record that the results were communicated to the physician as required. During an interview, a registered nurse confirmed that the results had not been documented as reported to the physician. Facility policy requires that such communication be documented in the Progress Notes section of the medical record, but this was not done in this instance.