Failure to Promptly Notify Physician of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic test results were promptly communicated to the ordering physician for a resident. The resident, who had a history of chronic obstructive pulmonary disorder and muscle weakness, was admitted to the facility and had intact cognition as assessed by a BIMS score of 13. Following a fall, the resident experienced uncontrolled head and neck pain, prompting a cervical spine x-ray. The x-ray, completed later that day, revealed an apparent right-lung infiltrate and recommended a follow-up chest x-ray for further evaluation. A review of the clinical record showed no documentation that the physician was notified of the abnormal x-ray findings or that the recommended follow-up chest x-ray was completed. During an interview, the DON was unable to provide an explanation for the lack of documentation regarding physician notification or review of the x-ray results. The DON confirmed that it is the facility's responsibility to ensure prompt communication of laboratory and diagnostic test results to the physician.