Failure to Promptly Notify Provider of Abnormal TSH Lab Result
Penalty
Summary
A resident with a diagnosis including hypothyroidism was admitted to the facility and had a physician order for laboratory tests, including a thyroid stimulating hormone (TSH) test, due to an elevated previous result. The TSH lab was drawn, but the result was pending at the time other lab results were reported to the nurse practitioner. Documentation indicated that all lab results were reported to the provider, but the TSH result was not available at that time. The facility failed to obtain and communicate the TSH result, which was significantly elevated, to the ordering practitioner in a timely manner. The TSH result became available later on the same day it was drawn, but there was no evidence that the facility obtained or reported this result to the provider until it was brought to their attention by surveyors during the survey. The nurse practitioner was only notified of the abnormal TSH result after the surveyor's inquiry, and this notification occurred after the resident had already attended an endocrinology appointment. Staff interviews confirmed that the TSH result was not communicated to the provider prior to the surveyor's intervention.