Failure to Promptly Notify Physician of Lab Results
Penalty
Summary
The facility failed to promptly notify the infectious disease physician of laboratory results for one resident who required weekly lab monitoring as ordered by the physician. The resident, a female with severe cognitive impairment, diabetes, anxiety disorder, and multiple pressure ulcers including a stage 4 ulcer, was admitted with orders for weekly CRP, BMP, and CBC labs to be faxed to her infectious disease doctor. Although the facility obtained the required labs on three separate occasions, there was no documentation or confirmation that these results were sent to the physician as ordered. Interviews with the resident's family and the infectious disease doctor's clinic revealed that the clinic did not receive the lab results despite multiple requests and follow-up calls to the facility. The clinic only received one set of labs after the resident was discharged. Facility staff, including the ADON and DON, could not confirm or provide documentation that the labs were sent as required. This failure was not in accordance with the facility's own policy, which requires staff to document when, how, and to whom lab results are provided.