Failure to Notify Providers of Outstanding and Completed Lab Results
Penalty
Summary
The facility failed to notify ordering practitioners when laboratory tests were not performed and did not promptly communicate laboratory results to providers for multiple residents. For one resident with diabetes, a comprehensive set of labs was ordered, but the A1c result was missing from the medical record and not communicated to the provider, despite being significantly elevated. The provider was not made aware of this critical result until several weeks later. Additionally, there were multiple instances where laboratory orders for other residents were not drawn or collected, and there was no documentation that providers were notified of these outstanding labs. Interviews with providers and facility staff revealed ongoing issues with the facility's process for obtaining, documenting, and communicating laboratory results. Providers reported frequent difficulties in accessing lab results, with some stating they had to repeatedly request the same labs or directly contact the facility to obtain results. The Assistant Director of Nursing confirmed that numerous lab orders remained outstanding without provider notification, and providers expressed concern about the lack of a structured system for managing laboratory information in the electronic medical record.