Failure to Notify Physician of Unsuccessful Lab Draws
Penalty
Summary
The facility failed to notify a resident's physician when laboratory tests ordered for the resident were not successfully drawn for three consecutive days. The resident, who had diagnoses including diabetes mellitus and hypertension, was admitted with intact cognition and required full assistance with activities such as toileting, showering, and dressing. An order for routine laboratory tests was placed, but the laboratory was unable to obtain the required blood samples over three attempts. Despite these unsuccessful attempts, the physician was not informed of the issue. The resident expressed frustration over the repeated failed blood draws, and both a Licensed Vocational Nurse and the Director of Nursing confirmed during interviews that the physician should have been notified after multiple unsuccessful attempts. The facility's policy requires prompt notification of the resident, physician, and representative regarding changes in the resident's condition or status, which was not followed in this instance. This lack of communication resulted in a delay in care and treatment for the resident.