Failure to Promptly Notify Physicians of Laboratory Results
Penalty
Summary
The facility failed to promptly notify physicians of laboratory results for two residents, resulting in a deficiency. For one resident with a history of fractures and essential hypertension, a stat D-dimer test was ordered after the resident experienced shortness of breath and was placed on oxygen. The D-dimer result, which was significantly elevated, was received by the facility but not communicated to the physician until two days later. During this period, there was no documentation of physician notification or follow-up regarding the abnormal result, despite the resident's ongoing symptoms and the critical nature of the test. In the second case, a resident with multiple diagnoses including diabetes, heart disease, and mood disorders had a valproic acid level ordered and collected. The laboratory result was received and reviewed in the system, but there was no documentation that the physician or psychiatric provider was notified of the result or that it was reviewed, despite facility policy requiring such notification and documentation. Progress notes and psychiatric notes did not reference the lab result, and the Director of Nursing confirmed the absence of documentation regarding review or notification. Interviews with nursing staff and the DON revealed inconsistencies in the process for tracking and communicating lab results. Staff described reliance on shift-to-shift communication and lab books, but there was no consistent use of a daily log or clear documentation of physician notification. Facility policy required prompt notification of lab results to physicians and documentation of such actions, but these procedures were not followed in the cases reviewed, leading to delays in physician awareness and potential delays in care.