Failure to Promptly Notify Physician of Abnormal Anticonvulsant Lab Results
Penalty
Summary
The facility failed to promptly notify and follow up with the ordering physician regarding laboratory results that were outside of the clinical reference range for one resident with a seizure disorder. Specifically, the resident had active orders for Phenytoin (Dilantin) and Phenobarbital to manage seizures, and laboratory results collected and approved showed both medication levels were low. Despite this, the physician was not notified of the abnormal results until 20 days later, after a state surveyor brought the issue to the attention of the Assistant Director of Nursing (ADON). The physician subsequently gave orders to adjust the medication dosages and recheck levels. Interviews revealed that the ADON expected charge nurses to notify the physician of abnormal labs but assumed the physician was reviewing results in the electronic medical record system, which the physician was unable to access due to technical issues. The facility's policy required prompt notification of abnormal lab results to the ordering provider, but this was not followed. The ADON and Director of Nursing (DON) were identified as responsible for monitoring and overseeing labs, but the process failed in this instance, resulting in a significant delay in physician notification.