Failure to Notify Practitioner of Abnormal Lab Result
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify the ordering practitioner of an abnormal laboratory result for a resident who was tested for influenza A, RSV, and COVID-19 following an acute visit for a new problem. The laboratory swab was collected and resulted in a positive influenza A finding, which was marked as abnormal. However, the nurse manager documented in a late entry note that the lab results were negative and later admitted to being unaware of the positive result. The only evidence of the positive result was a scanned copy of the faxed lab report, and there was no documentation confirming that the nurse manager had notified the nurse practitioner of the abnormal finding. Interviews with the DON and the nurse practitioner confirmed that neither was aware of the positive influenza A result until informed by surveyors. The DON stated that she expected the provider to have been notified, and the nurse practitioner indicated she would have treated the resident for influenza A had she been informed. The facility's policies required timely notification of abnormal lab results to the attending physician or designee, but this was not followed in this instance.