Failure to Ensure Nursing Staff Competency in Interpreting and Reporting Critical Lab Values
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with complex medical needs. A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anemia of chronic disease was admitted and had laboratory tests ordered. The results showed severely abnormal values, including a high WBC, low hemoglobin, and low hematocrit. The LVN on duty sent a picture of the lab results to the resident's physician via text but did not clarify or address the abnormal findings beyond reporting the results and responding to a question about water flushes. The physician's response only addressed fluid status, and no further clarification or action was taken regarding the critical lab abnormalities at that time. Later, another LVN contacted the physician due to the resident's low blood pressure and, after some confusion about the resident's identity, provided the lab values when prompted by the physician. Only then did the physician order additional diagnostic tests and treatments, including blood cultures, a urine test, chest x-ray, antibiotics, and IV fluids. The resident's condition continued to deteriorate, leading to a transfer to an acute care hospital. Interviews with facility staff revealed that the LVN responsible for initially reporting the lab results did not express concern about the abnormal values and stated she was just following orders. Other nursing staff indicated that proper procedure would have included assessing the resident, highlighting significant lab results, and ensuring the physician was aware of the critical findings. The Director of Nursing and the Director of Staff Development both acknowledged that nurses are expected to question unclear orders and have a basic understanding of lab values, but orientation only included a brief review of lab values without specific competency verification.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The DON/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 7/30/25