Failure to Communicate Critical Lab Result Leads to Resident Death
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to notify the physician of an elevated PSA result and document follow-up. A resident with schizophrenia and depressive disorder had a PSA of 18.2 ng/mL, but the chart showed no documentation that the MD was notified of the abnormal lab. Notes later referenced urology referral and appointment scheduling, but the DON/ADON could not identify documented notification or timely follow-up in the EMR.
A resident with COPD, DM2, and infection risk developed nausea, vomiting, and diarrhea, and an NP ordered stat CBC/CMP and stool testing for C. difficile. The lab reported the stool result as detected, but the facility did not review and notify the NP until about 17 hours later. Nursing notes and interviews showed the result was not checked promptly despite expectations that lab results be reviewed each shift and reported immediately.
A resident with G-tube status, chronic respiratory failure with hypoxia, and a subdural hematoma had a sputum culture showing heavy growth of ESBL-producing Klebsiella pneumoniae, but the record did not show that the attending MD or pulmonologist was notified. The nursing notes lacked documentation of notification or follow-up orders, and the SBAR COC addressed only G-tube dislodgement, not the critical lab result.
Failure to obtain ordered TSH monitoring for a resident receiving levothyroxine. A physician ordered repeat TSH testing for low thyroid hormone, but the lab was not completed and the resident continued on therapy without the ordered monitoring. The consultant pharmacist later recommended a TSH recheck, yet the record showed no documentation that the lab had been obtained. The ADON, DON, and physician all stated the TSH order should have been placed or completed.
A resident with an abdominal wound, ileostomy, and history of sepsis had a wound culture that grew E. coli, but the result was not promptly reported to the ordering practitioner. Staff documented the culture result, discussed the resident’s pain and redness, and noted the resident asked about antibiotics, yet the NP was not notified until several days after the lab finalized. Interviews with the wound care nurse, LPN, NP, DON, ADON, and Administrator confirmed the delay in communication and treatment.
A resident with ASHD and HF was receiving Atorvastatin, Furosemide, and KCl ER, with ordered routine CMP and lipid panel monitoring. The record showed the required labs were not obtained when due, and RN and DON/ADON interviews confirmed the CMP and lipid panel were missed for the month without surveyor intervention.
Failure to Notify Physician of Elevated PSA Result
Penalty
Summary
The facility failed to notify the physician of an elevated PSA laboratory result for one resident and failed to document physician notification or timely follow-up after the abnormal result was identified. The resident was admitted with diagnoses including schizophrenia and depressive disorder, and later assessments showed the resident required supervision or touching assistance for toileting hygiene and oral hygiene. The resident’s record showed a PSA result of 18.2 ng/mL from a laboratory test dated 1/28/2026. Subsequent progress notes and physician notes repeatedly referenced the PSA as outside the reference range and documented a referral to urology. The resident’s care plan also identified the PSA level as elevated and included a urology consult for evaluation and treatment. Appointment notes later showed scheduling and rescheduling of a urology appointment, and one appointment was canceled because the resident was unable to sign consent forms and was under conservatorship. During concurrent interview and record review, an LVN stated the physician should have been notified of the abnormal PSA result and that notification should have been documented in the progress notes. The record review revealed no documentation that the physician had been notified of the elevated PSA level. The ADON stated nursing staff were responsible for reviewing lab results, notifying the physician, and documenting the notification, but she could not identify who notified the physician or when because there was no documentation in the electronic record. She also stated there was no documentation that the conservator had been contacted after the urology appointment was canceled, and that no repeat PSA or follow-up laboratory tests were ordered.
Delayed Notification of Positive C. difficile Lab Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of abnormal laboratory results for one resident who had been admitted with diagnoses including acute respiratory failure, COPD, legal blindness, anxiety, and type 2 diabetes. The resident was also identified as being at risk for infection or recurrent/chronic infection related to a compromised medical condition. Her care plan directed staff to report changes in condition to the MD as clinically indicated. The resident developed nausea, vomiting, and diarrhea, and an NP approved stat CBC/CMP and a stool specimen for C. difficile testing. Nursing documentation shows the stool specimen was collected and sent to the lab, and the NP was later told the stool culture was still pending. The lab received the specimen and reported the result to the facility at 9:47 p.m., with the result showing C. difficile detected. However, the facility did not review the result until 2:50 p.m. the next day, approximately 17 hours after the result was sent to the facility. When the result was finally reviewed, nursing documented that the NP was notified and a new order for vancomycin and contact precautions was received. Interviews with nursing leadership and staff indicated that lab results were expected to be checked each shift, but the positive C. difficile result was not acted on in a timely manner. The facility’s own education on critical laboratory value reporting stated that critical lab values must be received by a licensed nurse, verified, reported immediately to the provider, documented completely, and acted upon without delay.
Failure to Notify Physician of Critical Sputum Culture Result
Penalty
Summary
The facility failed to ensure the physician was notified of an abnormal laboratory result for one resident. The resident was admitted with diagnoses including gastrostomy status, chronic respiratory failure with hypoxia, and nontraumatic subdural hematoma. A sputum culture collected from the resident showed heavy growth of ESBL-producing Klebsiella pneumoniae, and the final result was approved and called to a nurse as a critical sputum culture result. However, the nursing progress notes did not show documentation that the attending physician or pulmonologist was notified of this critical result, and there was no documented evidence of follow-up instructions or treatment orders in response to the finding. The resident’s SBAR change of condition report documented a separate issue of G-tube dislodgement and transfer to the hospital, but it did not identify or address the critical sputum culture result. During interviews, the Operations Manager and DON stated that critical infection-related laboratory results should be reported to the physician, documented in the nursing progress notes, and communicated through a change of condition report. The DON reviewed the sputum culture and confirmed that the pulmonologist should have been notified and that a COC should have been completed, but the record review did not show that this occurred.
Failure to Obtain Ordered TSH Monitoring
Penalty
Summary
The facility failed to ensure physician-ordered laboratory services were provided for Resident #13, who was receiving levothyroxine for low thyroid hormone. A physician order dated 06/26/2025 directed that TSH be repeated in three weeks, but review of the medical record showed the ordered TSH laboratory test was not obtained. The resident continued levothyroxine therapy without the ordered thyroid monitoring, and review of the consultant pharmacist’s monthly medication regimen review dated April 2026 recommended a TSH recheck in six months to one year, with no documentation that the laboratory monitoring had been completed. Physician progress notes from January 2026 through July 2026 did not show that the original TSH order had been discontinued or modified. During interviews, the ADON stated the resident’s last TSH was obtained in 2024 and was unsure why follow-up testing had not been completed, the DON stated she would have expected the TSH order to have been entered, and Physician #1 stated the TSH order should have been placed.
Delayed Reporting of Positive Wound Culture
Penalty
Summary
The facility failed to ensure that abnormal lab results were promptly reported to the ordering practitioner for one resident. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery, diverticulitis, sepsis, and an open abdominal wound. Her care plan identified risk for skin breakdown related to a new ileostomy, indwelling catheter, and impaired mobility, with instructions to observe for signs of infection or delayed healing and report them to the physician as needed. The resident was cognitively intact with a BIMS score of 15. On 6/22/26, the wound care nurse observed excessive drainage from the abdominal wound during dressing care, noted the ileostomy site was soiled, and notified the MD, who ordered a wound culture. The specimen was collected on 6/22/26, received by the lab on 6/23/26, and resulted positive for Escherichia coli on 6/25/26 at 12:14 p.m. Nursing documentation showed the resident later complained of pain and redness at the site, and on 6/27/26 the resident asked about antibiotics and was told the culture result was being reviewed and that the upcoming nurse should message the MD in the morning. The positive culture was not communicated to the NP until 6/28/26, when the wound culture result was reviewed and new orders were obtained for a midline/PICC and ertapenem. The resident stated she believed she was already receiving antibiotics and said she was told the culture was positive and placed in the file without follow-up to the doctor. Staff interviews confirmed the delay: the wound care nurse said she assumed the resident knew about antibiotics, the LPN said she did not know the culture was pending, the NP said she was first notified on 6/28/26 and should have been notified right away or the next morning, and the DON, ADON, and Administrator all confirmed the delay in reporting and treatment.
Missed Ordered CMP and Lipid Panel Monitoring
Penalty
Summary
The facility failed to ensure ordered laboratory testing was obtained for a resident with a history of ASHD and heart failure who was receiving Atorvastatin 40 mg at bedtime, Furosemide 40 mg twice daily, and Potassium Chloride ER 20 mEq every morning. The physician had ordered a CMP every three months in March, June, September, and December, and a lipid panel every six months in June and December. The lab order for routine monitoring was provided on 05/20/26, but the resident’s record showed the last CMP was obtained on 04/14/26 and there was no evidence that a CMP or lipid panel was obtained in June 2026. During interview, RN #160 stated that lab orders were entered into the computer, appeared on the TAR when due, and the night shift nurse would review the TAR and complete lab slips for the labs to be drawn by the hospital lab technician. She reported the lab slips for the day had already been filled out and denied any labs were due that day for the resident. The DON and ADON were asked for documentation of any CMP or lipid panel obtained for the resident, and the ADON provided only the 04/14/26 CMP. She denied that a CMP or lipid panel had been obtained in June 2026 and acknowledged the resident’s CMP and lipid panel would have been missed for that month without surveyor intervention.
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