F0773

G

Failure to Review and Communicate Critical Lab Result to Physician

Midland, Texas Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly review and communicate critical laboratory results to the attending physician in accordance with its Lab Monitoring and Lab Orders policies. A male resident with schizoaffective disorder, bipolar type, PTSD, and constipation, but no history or diagnosis of diabetes and no orders for insulin or blood glucose monitoring, reported abdominal discomfort and gastrointestinal issues. A nurse practitioner ordered a CBC and CMP after the resident complained of foul bowel odor, bad breath smell, and nausea. The following day, the lab drew the ordered tests, and the laboratory report showed a critically elevated blood glucose level of 934 mg/dL, with documentation that the critical result was called directly to the resident’s physician by the lab technician. The facility was not contacted by the lab, and there is no documentation that the physician notified the facility of the critical value.

Facility staff did not identify or act on the critical lab result in a timely manner despite having access to the results through the Ring App and despite facility policy requiring that all lab results be reviewed by a nurse, dated and timed, and that critical values be called to the physician immediately. The 24-hour report noted that labs were done and described them as having a “negative outcome,” but did not document the critical glucose value or any physician notification. The ADON later printed the lab results from the Ring App and handed them to the nurse on duty, instructing her to contact or call the physician, but he stated he did not review the results himself. The nurse who received the printed results stated she did not review the lab values, assumed the ADON had already reviewed them, and only faxed them to the physician because the report indicated the physician was already aware. She did not confirm receipt of the fax and did not document any direct notification or follow-up with the physician regarding the critical value.

Over the subsequent days, the resident continued to experience symptoms, including nausea and bowel issues, and asked staff about his lab results. One nurse directed him to ask another nurse, and the nurse who had been given the printed results denied that the resident asked her to read the results. On a later shift, another LVN observed that the resident appeared pale and was “talking differently,” prompting her to check his vital signs and then review the Ring App, where she saw the critically high glucose value of 945 mg/dL. She then checked the resident’s blood sugar with the facility glucometer and obtained a reading of 478 mg/dL, after which the resident was sent to the hospital. Interviews with the NP, Medical Director, ADONs, and nursing staff confirmed that the facility’s policies required nurses to review lab results, document the date and time of review, and promptly notify the physician of abnormal and critical values, and that this process was not followed for this resident’s critical glucose result. The failure to promptly notify the physician of the critical lab value and to follow the lab monitoring and lab orders policies constituted the deficiency.

The report also documents that the facility’s Lab Monitoring policy required all lab results to be reviewed by a nurse, with the nurse dating and documenting the time the result was reviewed, and that critical lab results be called to the physician or on-call physician immediately. The Lab Orders policy required the facility to ensure timeliness of services, monitor lab orders daily, and ensure that all lab results were communicated to the physician in a timely manner, with proof of notification included on the lab report or in nurse’s notes. Interviews with the Administrator, ADON, and Medical Director confirmed that nurses were expected to review lab reports before forwarding them, to notify the physician of critical values, and not to assume that the physician had already been informed. In this case, multiple staff members acknowledged that the critical glucose value was not recognized or acted upon as required, and that the facility did not follow its own policies for lab review, tracking, and physician notification for this resident’s critical lab result.