Failure to Notify Ordering Practitioner of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the ordering practitioner of abnormal laboratory test results for one resident. The resident, who had multiple diagnoses including obstructive sleep apnea, chronic kidney disease, chronic atrial fibrillation, and congestive heart failure, was admitted with a telephone order from a nurse practitioner for a basic metabolic panel (BMP) to be drawn at the facility. The order was signed off by a nurse, and the blood specimen was collected and reported to the facility. The lab results, which included several out-of-range values, were reviewed by the Medical Director several days later, but the results were not communicated to the nurse practitioner who ordered the test. Interviews with facility staff and the Medical Director revealed confusion and lack of clarity regarding who was responsible for reporting lab results to the ordering provider. The patient access representative at the cardiology office confirmed that the results were never received, and additional blood work had to be ordered and completed at an offsite provider. The Assistant Director of Nursing stated that the nurse assigned to the resident's hall should have reported the results, while the Director of Nursing and Administrator were unsure of the policy. The Regional Nurse Consultant indicated that typically the unit manager would notify the prescribing provider, but anyone could communicate the results.