F0684

E

Failure to Promptly Communicate Critical Lab Results Leading to Delayed Hospital Transfer

Galloway Township, New Jersey Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s critical laboratory results were promptly and effectively communicated to the attending physician, resulting in a three‑day delay in physician notification and subsequent transfer to the hospital. The resident had multiple significant diagnoses, including acute respiratory failure, heart failure, COPD, type 2 diabetes, and a history of low platelet counts, and had recently completed antibiotics for pneumonia. The resident’s care plan identified risk for bleeding and bruising related to Plavix use, with an intervention to obtain labs as ordered and report abnormal results to the physician as soon as possible. Weekly CBC and BMP labs were ordered, and on 12/8 the resident’s platelets were already low at 59 K/CU.MM, with the physician’s subsequent progress notes referencing trending labs.

On 12/15, a CBC and BMP were collected and later reported with critical abnormalities, including a platelet count of 20 K/CU.MM, elevated creatinine of 1.99 mg/dl, sodium of 130 mmol/L, and an eGFR of 27. A nursing progress note dated 12/16 documented that the lab called with critically low platelets (20) and that the physician was notified with no new orders, but the physician later stated he was not called about these labs at that time. Instead, the overnight LPN sent a text message to the physician around 1:28 AM reporting the critical platelet count and asking for orders, and then sent a second text at 5:26 AM about another resident’s dark red urine. The physician responded at 6:23 AM with two brief texts, “Noted” and “Hold Eliquis,” which he and the facility later clarified were in response to the second resident’s issue; he stated he never saw the earlier text about the critical platelet count, and no direct voice communication occurred regarding the critical labs.

Over the next two days, there was no documented direct physician notification or follow‑up regarding the critical platelet count and worsening renal function, and no new orders were obtained based on those results. The overnight LPN reported that she assumed the physician’s text responses applied to both residents and endorsed to day shift that the critical labs had been communicated and that there were no new orders, expecting the physician to see the resident. The physician later confirmed that he only became aware of the critical labs when a unit manager called him on 12/18 after the resident’s responsible party questioned the lab results and lack of physician contact during a care plan meeting. Upon reviewing the labs at that time, the physician instructed that the resident be sent to the ER for evaluation due to the drop in platelet count and abnormal blood counts. The resident was transferred with the stated reason of a drop in platelet count and was subsequently admitted to the hospital with septic shock and pneumonia. Facility leadership, the physician, the medical director, and multiple nurses acknowledged that critical labs were expected to be communicated emergently by direct phone call, not solely by text, and that in this case there was a delay in care and treatment due to the failure to promptly and effectively notify the physician of the critical results.

Interviews with the physician, medical director, DON, ADON/IP, and nursing staff further established that facility policy and expectations required direct voice communication for critical results, with escalation to the medical director if the attending physician did not respond within a specified time. The physician stated that critical labs must be called in emergently and that, had he been made aware immediately, he would at least have considered additional lab surveillance, escalation of care, or hospital evaluation. After later reviewing the chart, he noted that the substantial decline in renal function, which was not included in the initial text, would also have prompted emergency intervention. The medical director reported that he had previously educated staff that critical results, including labs, radiology, and ultrasounds, must be communicated by phone rather than text because texts are short and can create confusion. The facility’s own policies on lab/diagnostic results and acute condition changes required prompt physician notification, direct voice communication for urgent results, and contacting the medical director if the attending physician did not respond, but these standards were not followed in the handling of this resident’s critical laboratory findings.

The resident’s responsible party reported learning during a care plan meeting that lab results had been available for three days without a physician call, and the physician confirmed he had not been notified until contacted by the unit manager on the day of transfer. The LNHA later stated he could not locate a formal investigation specific to the critical lab delay, while the ADON/IP stated she had reviewed the medical record and text messages as part of a review of acute discharges and acknowledged a delay in care. The DON also acknowledged a delay in treatment. Overall, the sequence of events shows that the facility did not ensure that critical lab results obtained on 12/15 were immediately and effectively conveyed to the physician, contrary to professional standards of practice, facility policy, and the resident’s care plan interventions, resulting in a three‑day delay in physician notification and transfer for evaluation and treatment.