Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician of abnormal laboratory results, specifically a high blood glucose level, low sodium, and low chloride, as indicated in lab results dated 5/22/2025. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM), was experiencing increased confusion and poor food intake, prompting the physician to order a series of lab tests. While the physician was notified of earlier abnormal results and ordered further testing, there was no documented evidence that the subsequent abnormal results were communicated to the physician. Interviews confirmed that the physician was not made aware of the abnormal lab findings from 5/22/2025, and the Director of Nursing acknowledged that the physician should have been notified. The facility's policy required prompt notification of lab results outside clinical reference ranges, but this was not followed in this instance, resulting in the physician being unaware of the resident's condition and a delay in care and treatment.