Delayed Provider Notification of Laboratory Results
Penalty
Summary
The facility failed to ensure that two residents received appropriate and adequate healthcare services due to delays in notifying the ordering provider of laboratory results. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The lab specimen was collected and the results, which were significantly elevated, were reported to the facility in the evening. However, there was no documentation that the physician was notified of these results until the following morning, resulting in a delay in further medical evaluation and intervention. For another resident, laboratory tests were ordered and completed, with results received and reviewed by staff. Despite this, there was no documentation that the physician or provider was notified of the results or that the results were reviewed by the provider. Progress notes and interviews confirmed the absence of documentation regarding provider notification or review of the lab results, even though the resident had a complex medical and behavioral history and was undergoing medication changes that warranted close monitoring. Interviews with nursing staff and the Director of Nursing revealed inconsistencies and gaps in the process for tracking, documenting, and communicating laboratory results to providers. Staff described reliance on verbal handoffs and incomplete use of lab tracking logs, and acknowledged that results were sometimes not promptly communicated to physicians. The facility's own policy required prompt notification of lab results to providers, but this was not consistently followed, as evidenced by the delays and lack of documentation in these two cases.
Plan Of Correction
N201 Right to Adequate and Appropriate Health Care Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from the facility. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Other current residents with lab orders in the last 30 days from , were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur, what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. N0201