Failure to Document Lab Results and Physician Communication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document laboratory results and the communication of those results for a resident with multiple serious diagnoses, including acute kidney failure, cerebral infarction, and congestive heart failure. The resident was unable to make reasonable and consistent decisions, as indicated by their Minimum Data Set assessment. Physician orders required several lab tests, which were performed and returned with multiple abnormal results, including elevated white blood cell count, abnormal electrolyte levels, high blood glucose, impaired kidney function, and abnormal liver function tests. Despite the receipt of these abnormal lab results, there was no documentation in the resident's nursing progress notes to indicate that the results were communicated to the physician on the day they were received. The LVN stated that she printed the lab results, took photos, and texted them to the physician, believing that this method was sufficient and that further documentation in the medical record was unnecessary. This practice was contrary to facility policy, which required all care and communications, including lab data and their disposition, to be documented in the resident's medical record. The Director of Nursing confirmed that it was the responsibility of all licensed nurses to document all care provided, including communication with physicians, in the resident's medical record. Facility policies reviewed also emphasized the need for accurate and complete documentation of residents' status, care, and laboratory data in the medical record. The lack of documentation resulted in an incomplete and inaccurate depiction of the resident's well-being and had the potential to disrupt continuity of care.