Failure to Notify Provider of Critical Lab Results Due to Missed Communication
Penalty
Summary
The facility failed to promptly notify the ordering provider of critical laboratory results for a resident with multiple serious medical conditions, including severe chronic kidney disease, diabetes, and a history of heart surgery. On two separate occasions, critical lab results were reported by the laboratory, which attempted multiple times to contact the facility during early morning hours. Facility staff did not answer the phone during these attempts, and there was no documentation that staff returned the lab's calls or communicated the critical results to the provider. Additionally, the nurse coming on shift was not informed about the lab draws or the critical results during shift change, and only became aware of the situation when the resident's wife brought it to her attention. The Director of Nursing confirmed that the facility had ongoing issues with staff being unreachable by phone and lacked a message system for callers. The expectation was for staff to communicate critical lab results to the provider as soon as possible, but this did not occur in these instances.