Failure to Notify Physician of Critical Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to notify the ordering physician of laboratory results that were outside the clinical reference ranges for one resident. The resident, who had a complex medical history including bacterial arthritis, MRSA, diabetes, chronic kidney disease, congestive heart failure, pain, and edema, was receiving intravenous Vancomycin therapy via a PICC line. Multiple Vancomycin trough levels were reported as high on several occasions, but there was no documentation that the physician was notified of these abnormal results. Interviews with staff confirmed that the process required notification of the physician and documentation in the progress notes when lab results were abnormal. However, review of the resident's records did not show any evidence that the physician was informed of the high Vancomycin trough levels, nor was there documentation of any pharmacy recommendations for dose adjustment. The DON confirmed that such notifications and documentation should have occurred.