F0580

D

Failure to Notify Physician and Responsible Party of Abnormal Lab Results

La Mirada, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a physician and the responsible party of a change of condition related to abnormal lab results for one of five sampled residents. The resident had diagnoses including mild protein-calorie malnutrition and a urinary tract infection, and was documented as lacking capacity to make medical decisions, with severe cognitive impairment and dependence on staff for ADLs. A physician’s order directed that STAT labs, including a CBC, CMP, and urine culture and sensitivity, be obtained. The lab report from that testing showed an elevated WBC count of 15,200 cells/µL, above the normal reference range of 4,000–10,000 cells/µL.

Review of the SBAR communication form for that date showed that the physician and family were informed of the resident’s weight loss, but there was no documentation that the physician or responsible party were notified of the elevated WBC or that a change of condition (COC) was completed. During interviews, an LVN acknowledged that the WBC was elevated, that no COC was completed, and that the physician and responsible party should have been notified. An RN stated that any abnormal lab results should be reported to the physician and documented as a COC, and that the resident had a change from baseline labs warranting such action. The DON stated that nurses must complete a COC when labs are abnormal and notify the physician and responsible party so all are aware of the abnormal results. The facility’s “Notice of Changes” policy indicated the facility must inform the physician and/or family or legal representative when there is a significant change in the resident’s condition, such as deterioration in health, mental, or psychosocial status, which did not occur in this case regarding the elevated WBC.