Failure to Notify Provider of Abnormal Lab Result
Penalty
Summary
The facility failed to promptly notify the primary care provider of an abnormal laboratory result for one resident who was cognitively intact and required significant assistance with daily activities. The resident had diagnoses including atrial fibrillation, anemia, depression, long-term use of anticoagulants, and dysphagia. Orders were in place for annual blood tests, including a comprehensive blood count, basic metabolic panel, thyroid stimulating hormone, prothrombin time, and ferritin level. The medical record did not contain documentation of the lab work being drawn or the results, despite the resident receiving iron supplementation for anemia. Laboratory results from November showed an abnormally high ferritin level, but there was no documentation in the resident's progress notes or provider visit notes indicating that the results were reviewed or that the provider was notified. Interviews with nursing staff and the DON revealed that it was not the facility's practice to document labs drawn or lab results in the resident charts, and that nurse managers were responsible for reviewing and scanning lab results into the medical record. However, it was acknowledged that it would be difficult to determine if results had been reviewed or if the provider had been notified of abnormal findings. The facility's policy required timely reporting of lab findings to the ordering provider, but this was not followed in the case of the resident's elevated ferritin level, as there was no evidence of provider notification or review.