Failure to Timely Notify Physician of Critical Lab Values
Penalty
Summary
The facility failed to notify the physician of critical laboratory values in a timely manner for one resident. The resident, who had multiple diagnoses including hyperkalemia, heart failure, and thrombocytopenia, had physician orders for laboratory tests such as CBC, BMP, and Digoxin levels. Laboratory results revealed several critical values, including a Digoxin level of 3.50 ng/mL (normal 0.8–2.0 ng/mL), BUN of 107 mg/dL, chloride of 82 mEq/L, and potassium of 7.0 mEq/L. The laboratory attempted to fax these results to the facility multiple times without success, and the facility ultimately received the results by fax the following morning. Staff interviews confirmed that the LPN did not receive the critical laboratory values by fax or phone until the laboratory called early the next morning. The LPN also verified that the on-call physician was not notified of the critical values while the resident was still in the facility. The facility's policy required timely notification of lab results to the physician or other practitioners, but this was not followed in this instance.