Delayed Provider Notification of Critical Lab Results for UTIs
Penalty
Summary
The facility failed to ensure timely notification of critical laboratory results to the ordering practitioner for three residents who were being evaluated or treated for urinary tract infections (UTIs). In each case, there was a significant delay between when positive urine culture results were received and when the physician was notified and antibiotics were ordered. For one resident with chronic obstructive pulmonary disease, stroke, and malnutrition, a urine culture positive for Enterococcus faecalis was reported, but antibiotic therapy was not ordered until four days later. Another resident with Alzheimer’s disease and other comorbidities had a positive urine culture for E. coli, but antibiotics were not started until four days after the results were available. A third resident with acute kidney failure and other conditions had laboratory testing completed in the emergency room, but the facility did not follow up on the results until seven days later, when antibiotics were finally ordered. The Director of Nursing confirmed that the delays occurred, noting that some results were received on a Friday and not addressed until the following week, despite the facility having on-call physicians available during weekends. The facility’s policy states that delays in reporting and acting on laboratory results can adversely affect diagnosis and treatment, and requires nurses to promptly report critical findings to the prescriber and document this in the progress notes. The failure to promptly notify practitioners and act on critical lab results led to delays in the initiation of appropriate antibiotic therapy for the affected residents.