Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
Facility staff failed to ensure that abnormal laboratory results for a medically compromised resident were reported to the physician in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis, had physician orders for blood tests including Sedimentation Rate (ESR), C Reactive Protein (CRP), and a Basic Metabolic Panel. The laboratory results, which showed significantly elevated ESR and CRP levels indicating acute inflammation, were received by the facility but there was no documentation that these abnormal results were communicated to the resident's physician. Subsequent documentation showed that the resident developed cellulitis of the genital area and a new autoimmune disease-induced wound. The wound physician, upon reviewing the lab results days later, determined that the resident required transfer to the hospital for further evaluation and intravenous antibiotics. Interviews with facility staff and physicians confirmed that the abnormal lab results were not reported to the primary care provider or wound physician in a timely manner, and there was no documentation of provider notification in the medical record as required by facility policy.