Failure to Promptly Notify Physicians of Laboratory Results
Penalty
Summary
The facility failed to promptly notify physicians of laboratory results for two residents, as required by federal regulations and the facility's own policies. 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 laboratory result, which was significantly elevated, was received by the facility in the evening, but there was no documentation that the physician was notified until the following morning. Interviews with nursing staff and the Director of Nursing confirmed that the result was not communicated to the physician in a timely manner, and the delay was attributed to a lack of notification by the nurse on duty over the weekend. For another resident, laboratory results were received and reviewed by staff, but there was no documentation that the physician was notified or that the results were reviewed by the provider. The resident had a complex medical history, including diabetes, behavioral disturbances, and recent medication changes. Progress notes and provider documentation did not indicate that the abnormal lab results were communicated or addressed, despite facility policy requiring prompt notification and documentation of such communication. The facility's policy outlines a process for tracking, receiving, and notifying providers of laboratory results, including the use of a lab log and documentation of notification and any new orders. However, in both cases, the required steps were not followed, and there was a lack of documentation to show that physicians were promptly informed of critical or abnormal laboratory findings. This failure was confirmed through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and internal procedures.
Plan Of Correction
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. 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.