Failure to Promptly Notify Provider of Critical Lab Result
Penalty
Summary
The facility failed to promptly notify the provider of a critical laboratory result for one resident. According to facility policy, staff are required to immediately inform the ordering practitioner of laboratory results that fall outside the clinical reference range. In this case, a progress note documented that the resident had a critical sodium level of 161, but there was no evidence that the provider was notified immediately after nursing staff became aware of this result. Interviews with both an LPN and the Director of Nursing confirmed that the provider was not made aware of the critical lab value at the appropriate time. The delay in notification was further substantiated by a Nurse Practitioner note, which identified the resident's severe hypernatremia and documented that the resident was sent to the emergency department only after the Nurse Practitioner became aware of the critical lab value. The LPN confirmed during interview that both the provider and DON were not immediately informed, and acknowledged that critical lab values should be reported to the provider right away, as per facility policy.