Failure to Follow Up on Hemolyzed Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to timely follow up on hemolyzed laboratory results for a resident with a history of malignant melanoma and encephalopathy, who was at risk for complications related to cancer. The resident had physician orders for weekly complete blood count (CBC) tests, with results to be faxed to the oncologist. On one occasion, a CBC drawn was found to be hemolyzed and the laboratory requested a new order and recollection, but there was no documentation in the progress notes that the lab was redrawn or that the provider was notified. The resident's care plan included monitoring laboratory results as ordered, but this was not followed. Subsequently, several days later, the resident exhibited confusion and a new CBC was obtained, revealing a critically low hemoglobin level. The resident was then transferred to the emergency room and hospitalized for acute on chronic anemia, requiring multiple blood transfusions. Interviews with family and the oncologist's office confirmed that no CBC results were received during the period in question, and facility staff were unable to explain why the labs were not redrawn or the provider notified. There was no specific policy in place for handling hemolyzed samples.