Failure to Document Physician Notification and Response for Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident by not documenting physician notification and response after abnormal lab results were received. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness. A history and physical dated several days after admission indicated the resident had the capacity to understand and make decisions, and a subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for transfers and walking. An Interact Assessment Form dated 12/23/2025 showed the resident had an abnormal WBC of 15.2 and modest right lower lobe pneumonia. The form indicated that an LVN notified the physician, who ordered levofloxacin and additional blood tests including a CBC, CMP, and procalcitonin on 12/26/2025. A laboratory test result dated 12/26/2025 at 5:55 p.m. showed low hemoglobin and hematocrit, with a written note indicating the physician was notified on that date. However, when surveyors reviewed the resident’s laboratory results and progress notes with an RN on 1/14/2026, the RN confirmed that the progress notes did not document that the physician was notified of the abnormal blood test results. The RN stated there was no documentation of the time the physician was notified, who called the physician, or the physician’s response, including whether any new orders were given. In a separate concurrent review, the DON also confirmed that the progress notes lacked documentation of physician notification regarding the abnormal blood test result and acknowledged documentation issues in the resident’s medical record. The facility’s charting and documentation policy required that all services, changes in condition, and notifications, including date, time, name and title of the person providing care, assessment data, and notification of the physician, be documented in the medical record. The absence of this required documentation for the abnormal lab result rendered the resident’s medical record incomplete and inaccurate.
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