Delay in Provider Notification of Urgent EKG Results
Penalty
Summary
Facility staff failed to promptly notify the provider of urgent diagnostic results for a resident with a history of complete AV block, cardiac pacemaker, hypertension, and asthma. The resident experienced bradycardia and upper respiratory symptoms, and an EKG was ordered after persistent low heart rates were observed. The EKG report, which indicated severe bradycardia and possible third-degree heart block requiring immediate follow-up, was faxed to the facility at 12:47 AM. However, the provider was not notified of these urgent results until approximately 7:30 AM, resulting in a delay of several hours before action was taken. During this period, the resident continued to feel unwell and expressed significant fatigue. The delay in provider notification was confirmed through clinical record review and staff interviews, with staff stating that the results were not received or acted upon until the morning. Facility policy required prompt notification of abnormal diagnostic results to the ordering provider, but this was not followed in this instance, leading to a delay in the resident's transfer to the emergency room for further evaluation and treatment.