Failure to Promptly Report Lab Results to Physician
Penalty
Summary
A deficiency was identified when the facility failed to ensure that laboratory results were promptly reported to the physician for one resident. The medical record review showed that a resident with multiple diagnoses, including diabetes, morbid obesity, anemia, depression, kidney disease, and muscle weakness, had an order for an A1C test to be drawn on admission and every six months. The resident's care plan included obtaining lab work as ordered. The A1C result dated 02/12/25 was available, but there was no evidence that this result had been reviewed by the physician. Interviews with the DON confirmed that while lab work was kept in a binder and reviewed, there was no documentation or evidence that the physician had reviewed the specific A1C result for the resident. Facility policy required that nurses review lab results and contact the physician based on the immediacy of the results, but this process was not followed in this instance. This deficiency was identified during an investigation under a specific complaint.