Failure to Timely Report and Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results were reported and acted upon in a timely manner for one resident with chronic iron deficiency anemia and congestive heart failure. On 4/1/25, the resident's CBC results showed a critically low hemoglobin (Hgb) level of 7.2 g/dL and a low hematocrit (Hct) of 21.9%. The laboratory made two attempts to notify the facility by phone on the same day, but there was no documentation that the provider was notified of these critical results on 4/1/25 or 4/2/25. Nursing progress notes did not indicate any provider notification until 4/3/25, when the resident was found to be very lethargic with decreased verbal responsiveness. At that time, a nurse practitioner evaluated the resident, reviewed the lab results, and ordered a transfer to the hospital. Interviews with nursing staff and providers confirmed that neither the nurse practitioner nor the covering physician was made aware of the critical lab results prior to 4/3/25. Both providers stated they would have taken action had they been notified earlier. The facility's policy required immediate provider notification and documentation for critical lab results, but this was not followed. The DON confirmed that the expectation was for critical results to be called in to the provider immediately. The failure to notify the provider resulted in a delay in the resident's evaluation and transfer to the hospital, where the resident ultimately received a blood transfusion and had anticoagulant medication stopped.