Failure to Promptly Notify Provider of Abnormal Lab Results Delays UTI Treatment
Penalty
Summary
Facility staff failed to promptly notify the ordering provider of laboratory results that were outside clinical reference ranges for one resident, resulting in a delay in treatment for a urinary tract infection (UTI). The resident had significant medical conditions, including chronic renal failure stage IV, benign prostatic hypertension, and obstructive and reflux uropathy, and was assessed as having moderate cognitive impairment. Orders for urinalysis with culture and sensitivity were placed, and results indicating a UTI were available in the clinical record, but the provider was not promptly informed. Despite multiple urinalysis and culture results showing evidence of infection, there was no documentation that the provider was notified of these abnormal findings. The nurse practitioner (NP) continued to order repeat tests and was unaware of the previous positive results, as the laboratory results were not integrated into the chart in a timely manner. Nursing staff did not communicate the abnormal results to the NP, and the NP reported being unable to obtain information about the labs from staff during visits. Facility policy required nursing staff to identify and promptly communicate abnormal laboratory results to the attending physician, especially when results were problematic or the resident's clinical status was unclear. However, the policy was not followed, and the abnormal results were not conveyed to the provider, resulting in a significant delay in the initiation of appropriate treatment for the resident's UTI.