Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for one resident. The resident, an elderly female with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and aspirin therapy. Her care plan required immediate reporting of symptoms or lab findings indicating complications from these medications. On 4/10/25, laboratory results showed significantly low hemoglobin, hematocrit, and red blood cell count. Despite these abnormal findings, there was no documentation in the nursing progress notes between 4/10/25 and 4/25/25 indicating that the physician was notified of these results. The physician did not review the abnormal labs or provide further orders until 5/13/25, at which point a guaiac test was ordered. The facility subsequently collected only two of the three required stool samples for this test, and both were negative for occult blood. The Director of Nursing confirmed that staff should have immediately notified the physician of the abnormal labs and documented this action, but was unable to explain the delay in physician review or the incomplete collection of ordered tests. Facility policy required prompt physician notification and documentation for abnormal lab results, which was not followed in this instance.