Failure to Notify PCP and Responsible Party of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the primary care physician (PCP) and the resident's responsible party (RP) of abnormal blood test results for a resident with diagnoses of diabetes type 2 and congestive heart failure. The resident had orders for complete blood count (CBC) and comprehensive metabolic panel (CMP) tests, which were performed on two separate dates. The results from both dates showed several out-of-range values, including high glucose, blood urea nitrogen (BUN), BUN/creatinine ratio, carbon dioxide, RDW, absolute monocytes, absolute basophils, and low hemoglobin. A review of the resident's nursing notes revealed no documented evidence that the PCP or RP were informed of these abnormal results. During an interview, the Director of Nursing (DON) confirmed that licensed nursing staff did not notify the PCP or RP of the abnormal blood work. The facility's policy requires staff to notify the physician and document the communication, but this was not followed in this instance.