Failure to Notify Physician of Critical Lab Result
Summary
The facility failed to notify the ordering physician of a critical lab result for a resident with dementia who was admitted in 2024. On 10/9/24, laboratory tests revealed a critical hemoglobin level of 5.8 g/dL, which was reported to the facility the same day. The lab report indicated that a critical value was identified and the facility was contacted, but no staff were available to receive the result. The critical lab value remained unreviewed in the electronic health record due to a technical issue and a change in the phone system, and was not discovered by staff until 10/16/24. During this period, the resident developed abdominal pain, vomiting, and absent bowel tones, and was subsequently transported to the hospital. The delay in reviewing and communicating the critical lab result to the physician was confirmed through staff interviews and record review.
Penalty
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A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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