Failure to Provide 24-Hour On-Call Physician Services for Critical Lab Result
Penalty
Summary
Facility staff failed to provide 24-hour on-call physician services for one resident when a critical laboratory result was received. The resident had a potassium level of 2.9 mEq/L, which is below the normal range. Nursing staff documented that they attempted to contact the on-call physician multiple times during the early morning hours, but did not receive a return call. The progress notes indicate that the on-call physician was not reached despite repeated attempts, and the issue was not escalated to the medical director or backup provider as per facility expectations. Interviews with administrative and clinical staff confirmed that nurses are expected to reach an on-call physician at all times and should escalate to the medical director if unable to do so. The attending physician stated that there is always a backup provider available and that the on-call service has their contact information. He also confirmed he was not made aware of the resident's critical potassium level and would have ordered immediate treatment if notified. No additional documentation or policy regarding 24-hour physician coverage was provided prior to the survey exit.