Failure to Promptly Notify Practitioner of Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the ordering practitioner of abnormal laboratory results for a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with daily activities, had a wound specimen collected due to increased edema and purulent drainage. The laboratory results, which identified the presence of Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis in the wound, were sent to the facility but were not communicated to the nurse practitioner until several days later. The delay in notification occurred despite the facility's process for lab result review, which includes making results viewable on the Point-Click-Care system dashboard and requiring the overnight shift to conduct a 24-hour chart check to identify any oversights. The oversight was not recognized until several days after the results were received, at which point the practitioner was notified and appropriate medical interventions were ordered. The facility's policy requires prompt reporting of positive culture results to the practitioner, but this was not followed in this instance.