Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure timely physician notification of laboratory results for a resident who complained of bladder pain and pressure. A urinalysis (UA) was ordered and obtained, with results reported as within normal limits (wnl). Although the patient and family were informed of the normal UA results, the medical record did not show documentation that the physician was notified of these results, as required by facility policy. The resident, who had a history of atrial fibrillation, heart failure, and hypertension, was subsequently sent to the emergency room at the insistence of the patient and family, and was later diagnosed with a Pseudomonas urinary tract infection. The Director of Nursing confirmed that the facility policy regarding physician notification was not followed and that there was no documentation of physician notification in the medical record.