Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
A deficiency occurred when abnormal laboratory results for a resident were not reported to the resident's physician in a timely manner, nor were instructions for care obtained promptly. The laboratory results, which included significant abnormalities such as elevated sodium, blood urea nitrogen (BUN), creatinine, and liver enzymes, were received by the facility in the afternoon. Despite the facility's policy requiring notification of abnormal results to the physician, there was no documentation that the physician was notified on the day the results were received. The resident had a complex medical history, including acute kidney failure, cerebral infarction, and congestive heart failure, and was unable to make reasonable decisions according to the Minimum Data Set. The abnormal lab results indicated severe dehydration, hypernatremia, and impaired kidney and liver function. Nursing staff on the relevant shifts failed to document follow-up or notification of the physician. One nurse texted the results to the physician, contrary to the physician's stated preference for phone calls, and did not document the communication in the resident's progress notes. The physician acknowledged receipt of the text but did not review the results at that time, and no further action was taken until the following day. The delay in notifying the physician and obtaining care instructions resulted in a delay in transferring the resident to an acute care hospital for evaluation and treatment. When the physician was finally contacted the next day, the resident was transferred and treated for severe dehydration, hypernatremia, hypotension, and acute kidney injury. Interviews with staff and the physician confirmed that the facility's expectations and the physician's preferences for communication were not followed, leading to the delay in care.