Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or certified nurse practitioner (CNP) of laboratory results for one resident. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and urinary retention. The resident was cognitively intact at the time of the incident. Laboratory tests were ordered, including a complete blood count (CBC) and a basic metabolic panel (BMP), to establish a baseline and investigate causes of weakness such as anemia or electrolyte imbalance. The laboratory results showed several abnormal values, including elevated blood urea nitrogen (BUN), elevated carbon dioxide, low red blood count, low hemoglobin, and low hematocrit. Despite these findings, interviews with the Director of Nursing and the physician confirmed that neither the physician nor the CNP were notified of the laboratory results. Documentation indicated that the nurse was advised to ensure all follow-up was completed and that the specialist and CNP were notified, but this did not occur.