Failure to Notify Physician of Critical Lab Result
Penalty
Summary
The facility failed to take timely action on laboratory test results for one resident who was admitted with multiple complex diagnoses, including type 2 diabetes mellitus with hyperglycemia, anemia, chronic kidney disease, and a recent urinary tract infection. Upon admission, a physician ordered a Hemoglobin A1C test to monitor the resident's diabetes management. The lab result, reported two days later, showed a significantly elevated Hemoglobin A1C of 10.8. However, there was no documentation in the nursing progress notes that the physician was notified of this result. Subsequent physician orders for insulin management were made nearly two weeks after the lab result was available, with no evidence that the elevated A1C was communicated to the physician in a timely manner. During interviews, the DON acknowledged that the physician should have been notified of the results, and the physician could not recall being informed of the lab findings. This lack of timely notification and action on critical laboratory results constituted a deficiency in the facility's laboratory services for the resident.