Failure to Notify Physician of Critical Lab Result
Penalty
Summary
Facility staff failed to notify the ordering physician of a critical laboratory result for one resident. According to facility policy, staff are required to inform the prescriber of results that are outside clinical reference ranges and document this notification. In this case, a resident with diagnoses including breast cancer and cellulitis of the left lower limb had a critical BNP laboratory value reported. The clinical record showed that the critical result was received by a registered nurse, who documented unsuccessful attempts to reach the physician for review and indicated that further attempts would be made. Despite these efforts, there was no documented evidence that the physician was ever informed of the critical laboratory result. Interviews with facility leadership and the medical director confirmed a lack of clarity regarding why the nurse was unable to notify the physician. The clinical record review did not show any follow-up or confirmation that the prescriber was made aware of the critical value, as required by facility policy.