Failure to Notify Physician and Family of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to follow its policy and procedures regarding notification of a change in condition for a resident who developed unilateral leg swelling, pain, and abnormal diagnostic test results. Despite the resident's symptoms and subsequent orders for venous and arterial doppler studies, the facility did not notify the resident's emergency contacts or family about the change in condition or the abnormal findings. Documentation shows that family notification was excluded at multiple points, even though the facility's policy requires notifying the responsible party of all changes in condition. Additionally, the facility failed to accurately communicate abnormal diagnostic results to the physician. The physician was incorrectly informed that the venous doppler was negative for clots, when in fact it was positive for deep venous thrombosis. The physician only became aware of the true results upon personal review of the report days later. Staff interviews confirmed that abnormal results should be reported to providers, especially when positive, but this did not occur in this case.