F0773

J

Failure to Promptly Report Critical Lab Result and Change in Condition

Pearland, Texas Survey Completed on 11-28-2025

Penalty

No penalty information released

Summary

A deficiency occurred when the facility failed to promptly report a critical laboratory result to the ordering practitioner for a resident with multiple complex medical conditions, including cancer, end-stage renal disease requiring hemodialysis, heart failure, and acute kidney failure. The resident had a critical low blood glucose value of 42, which was identified after blood was drawn at dialysis. The laboratory notified the facility of this result, but the nurse on duty was unable to reach the physician and only sent a text message, receiving no response. No further escalation was attempted, and the Medical Director was not contacted as required by facility policy.

The resident had exhibited a change in condition, including confusion and cold extremities, on the evening prior to being found unresponsive. Staff had difficulty obtaining vital signs, particularly oxygen saturation, and these issues were reported among the care team. Despite these signs and the critical lab value, there was no documented evidence that the physician was promptly notified or that additional monitoring or interventions were initiated in response to the abnormal findings. The resident was later found unresponsive and was pronounced deceased by EMS.

Interviews and record reviews revealed that staff were aware of the abnormal findings and the facility's policies required immediate physician notification for critical lab results and changes in condition. However, the nurse did not follow the escalation protocol when the physician could not be reached, and there was a lack of timely and effective communication among the care team regarding the resident's deteriorating status. The failure to report the critical lab result and adequately respond to the change in condition constituted the identified deficiency.

Removal Plan

• RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition. During this education, the DON/designee reviewed the Handoff Communication policy to clarify expectations of correctly rounding residents at end and beginning of the shift.
• CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.
• LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.
• A root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.
• The NHA will oversee corrective actions and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action.
• Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
• All residents were identified to be at risk for the identified deficient practice. A random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. A random audit of all vital signs taken for all residents completed by DON or designee showed that there was a total of 8 residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. A random audit of all vital signs taken for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents: BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified; BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified; PR parameter for 1 resident that is not on any ACE, ARBs, Calcium or beta blocker was added after physician notification; 2 resident triggered as abnormal but after review is within normal limits of resident range of BP; 3 residents had over 100 PR but have medications administered.
• Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• A random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition.
• CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs.
• LVN B was provided 1:1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all LNs. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.