Failure to Notify Family of Critical Lab Value
Penalty
Summary
The facility failed to notify the family member of a resident regarding a critical lab value. The resident, who was moderately cognitively impaired and at risk for malnutrition due to hyponatremia and other medical conditions, had a critical serum sodium level of 99 identified in lab results. Although nursing notes documented that the resident was seen by a physician and an APRN, and that new orders were communicated to the family member, there was no documentation that the family member was specifically informed of the critical sodium level. Subsequent nursing notes indicated the initiation of intravenous hydration and further lab testing, with continued documentation that the family member was aware of new orders. However, at no point did the records show that the family member was notified of the critical lab value itself, as required by the facility's Notification of Changes policy. This omission constituted a failure to promptly inform the resident's representative of a significant change in the resident's condition.