Failure to Timely Report Critical Lab Results
Penalty
Summary
A deficiency occurred when the facility failed to report critical laboratory results in a timely manner for one resident. The resident, who had a history of moderate dementia, type 2 diabetes with neuropathy, and failure to thrive, was observed with changes in eating and self-care behaviors. Laboratory results collected in the early morning showed several critical and abnormal values, including a critically low glucose level of 21 mg/dL, elevated sedimentation rate, high white blood cell count, low hemoglobin, low hematocrit, and other abnormal findings. The facility was notified of these critical results in the afternoon of the same day. Despite receiving notification of the critical lab values, the nurse on duty did not immediately report the results to the resident's physician or document any recommendations. The nurse monitored the resident's blood sugar levels, which were within normal range later that morning, and determined that no further action was needed at that time. The following day, another nurse noticed the critical labs had not been reviewed or reported and subsequently notified the physician. Both the Medical Director and the Director of Nursing confirmed that the expectation was for nurses to report critical lab results to providers as soon as they are notified. The facility did not have a specific policy for reporting critical labs.