Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the medical provider of abnormal laboratory results for a resident with multiple complex medical conditions, including Type-2 diabetes, hypertension, long-term anticoagulant use, metabolic encephalopathy, pancreatic cancer, hypo-osmolality, hyponatremia, anemia, hypothyroidism, and a urea cycle disorder. The resident was admitted with severe cognitive impairment and had physician orders for a comprehensive metabolic panel (CMP) and complete blood count (CBC) with differential. Laboratory samples were collected and results, which included several abnormal values such as high sodium, high chloride, elevated glucose, elevated liver enzymes, high white blood cell count, and low hemoglobin and hematocrit, were reported to the facility in the early morning hours. Despite the presence of multiple abnormal and potentially critical lab values, there was no documentation in the resident's electronic medical record from the time the results were received through several days afterward indicating that staff had notified the medical provider. Interviews with nursing staff revealed uncertainty about the process for receiving and communicating lab results, especially during a period when the Director of Nursing (DON) was on vacation and agency nurses were covering shifts. Nurses stated that abnormal results should be called to the provider immediately and documented, but none recalled receiving or reporting the results for this resident. The Physician Assistant (PA) confirmed that the results should have been reported to the on-call provider and that she did not review the labs until several days after they were received. The DON and Administrator both acknowledged that the process for ensuring lab results were reviewed and communicated to providers was not followed during this period. The DON explained that unless nurses specifically checked the electronic medical record or were informed during shift change, they might not be aware of new lab results. The Administrator noted that oversight was lacking due to staff transitions and the absence of the DON, and that unit managers were supposed to follow up on labs but there was only one unit manager available at the time. There was no evidence that the abnormal lab results were communicated to a provider in a timely manner.