F0580

D

Failure to Notify Physician of Significant Change in Condition and Abnormal Lab Results

Windsor Locks, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely physician notification following a significant change in condition for one resident and abnormal laboratory results for another resident, as required by facility policy. One resident with dementia, poor decision-making skills, and a history of wandering was assessed as an elopement risk and care planned to wear a wander guard on the right ankle, with interventions to redirect if near exit doors and to check the device per protocol. On the date of the incident, this resident was discovered missing from their room during overnight rounds, and a search revealed the resident lying outside on the sidewalk with the upper body in the snow, blinking and responding to painful stimuli but nonverbal. The supervising RN brought the resident back inside, performed an assessment that showed low temperature and low pulses, provided warm blankets and care, and called emergency services, but the facility’s reportable event documentation and investigation did not identify that the physician was notified at the time of the incident.

Interviews and documentation further clarified the lack of timely physician notification for this event. The supervising RN reported notifying the Administrator, DON, and Infection Control Nurse before calling 911, but did not identify that he called the physician. The attending physician/Medical Director later stated he was not notified of the incident, and the facility’s on-call service confirmed that this physician was covering his own office during the relevant overnight hours with no other providers on call. The DON reported that the facility’s investigation could not determine whether the RN had notified the physician at the time of the incident. Facility policy on change in condition directed that the attending or on-call physician be notified when there is an accident or incident involving the resident, a significant change in condition, or a need to transfer the resident to a hospital or treatment center.

A second deficiency involved failure to notify a provider of abnormal laboratory results for another resident. This resident had diagnoses including influenza A, UTI, and hypothyroidism, and was care planned as being at risk for nutritional issues related to vitamin deficiency and hypomagnesemia, with interventions to obtain lab work as ordered and report abnormal findings to the physician. Laboratory results showed an elevated TSH of 9.73 u/mL, above the normal range of 0.34–5.60 u/mL, but the lab report lacked a physician signature of acknowledgment, and record review did not show that the physician was notified of these results. A later progress note by an APRN referenced a TSH result of 9 from the same time period and documented a plan to increase levothyroxine and recheck TSH, but the DON was unable to verify that nursing had notified a physician or APRN about the elevated TSH, and the attending physician stated he was on-site on two subsequent dates and was not notified of the lab results, contrary to the facility’s policy requiring notification of abnormal laboratory reports.