Failure to Provide Timely Care and Care Planning for Critically Low Hemoglobin
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with critically low hemoglobin levels. The resident, who had diagnoses including dementia and cognitive communication deficit, was admitted with low hemoglobin and had physician orders for biweekly CBC labs. On October 6, a lab result showed a critically low hemoglobin of 6.8 g/dl, which was reported to the facility multiple times by the laboratory, but staff were not reached until later. The licensed nurse documented notifying the physician the following afternoon and was awaiting a response, but there was no documentation that the physician addressed the critical result or that the resident was sent to the emergency room as per facility protocol for hemoglobin levels below 7 g/dl. Additionally, after the resident was readmitted from the hospital following a blood transfusion, there was no evidence of the required 72-hour monitoring. The resident's care plan did not include interventions for low hemoglobin at any point since admission, and there was no documented review to determine the cause of the low hemoglobin for further physician orders. The facility's policy required prompt physician notification and care plan revision for significant changes in condition, but these steps were not documented or implemented for this resident.