Failure to Notify Resident and Physician of Significant Diagnostic Test Result
Penalty
Summary
The facility failed to ensure that a resident was properly notified of a significant diagnostic test result and that appropriate follow-up was completed by the resident's physician. Specifically, a retroperitoneal ultrasound identified a 3.4 cm mass on the resident's right kidney, with recommendations for further imaging to differentiate the mass. Although progress notes indicated the resident was informed of the results and a nephrology referral was made, the resident later stated he was unaware of the kidney issue until a nephrology appointment months later. The nephrology nurse practitioner also reported not receiving the ultrasound results until the day of the appointment, due to the facility's delay in faxing the information. The resident had a history of diabetes mellitus and end stage renal disease, with cognitive skills intact and independence in activities of daily living. Documentation did not show that the resident was given a copy of the test results or that the physician was informed of the need for further imaging. The facility's policy required timely review, communication, and documentation of diagnostic results, but there was no evidence that these steps were followed, resulting in a delay in medical treatment and communication to both the resident and the physician.