Failure to Notify Providers of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that providers were notified of abnormal laboratory results for two out of three residents reviewed. In the first case, a resident with a complex medical history including end-stage renal disease, systemic lupus erythematosus, and chronic kidney disease experienced seizures and was noted by her representative to be lethargic, in pain, and not her usual self. Despite laboratory tests being ordered and drawn, the assigned LPN informed the resident's representative that results would be reviewed when the doctor returned and did not notify the provider of the abnormal findings, which included low iron, glucose, and chloride, as well as elevated BUN, creatinine, and potassium. There was no documentation in the progress notes that the physician was informed of these abnormal results, and the primary care provider confirmed he was not contacted regarding the resident's pain, change in condition, or lab values on that day. In the second case, another resident with end-stage renal disease, epilepsy, thrombocytopenia, and a history of transient ischemic attack had STAT labs ordered due to tremors and feeling cold. The labs, which revealed multiple abnormal values such as low RBC, hemoglobin, hematocrit, platelet count, and high neutrophils, were completed and available the same day. However, there was no documentation that the provider was notified of these abnormal STAT lab results. The provider's assistant stated that notification and documentation of such results would be expected, but neither she nor the provider recalled being notified, and the facility's records did not show evidence of such communication. Interviews with the DON and Regional Nurse Consultant confirmed that the facility's policy requires prompt notification and documentation of abnormal lab results, especially for STAT and critical values. They acknowledged discrepancies in physician notifications and verified that there was no documentation of provider notification for either resident prior to discharge. The facility's policy also specifies that such communications should be documented in the progress notes or on the lab results sheet, but this was not done in these cases.