Failure to Notify Wound Care Provider of Critical Lab Value Prior to Procedure
Penalty
Summary
The facility failed to notify the wound care provider of a resident's critically elevated INR lab value prior to performing wound care. The resident, who had a history of a stage four pressure ulcer to the left heel, atrial fibrillation, and a left hip fracture, was receiving warfarin therapy. On the day in question, the resident's INR was reported as 7.8, a value significantly above the therapeutic range, and this result was flagged in the laboratory report. Despite this, there was no documentation in the progress notes that the provider or the resident's family had been notified of the abnormal result. Subsequently, the wound care physician assessed and debrided the resident's left heel wound without knowledge of the elevated INR. During the procedure, the wound bled heavily and required cauterization and pressure bandaging. Interviews with facility staff confirmed that the wound care nurse and physician were not informed of the critical lab value prior to the procedure. The facility's policy required prompt notification of changes that may necessitate an alteration in treatment, but this was not followed in this instance.