Failure to Notify Practitioners and Document Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify practitioners of abnormal laboratory results and to document such notifications as required by facility policy and resident care plans. For one resident with a primary diagnosis of a left ilium fracture and a care plan for hypothyroidism, a TSH level of 26.99 (reference range 0.45–5.33 uIU/mL) was reported by the lab on 3/7/26 at 5:55 p.m. The record later showed an order on 3/9/26 to increase Levothyroxine to 200 mcg daily and to repeat the lab in a week, and a nursing note that the resident’s son was informed of the medication increase and repeat lab. However, the documentation did not show that the practitioner was notified of the abnormal TSH result at the time it was reported, despite the care plan intervention to obtain and monitor labs and report results to the MD. Another resident with hypothyroidism had increased confusion documented, and the ARNP was notified with a request for labs. A urinalysis with microscopic exam was ordered and later reported with abnormal findings for urine blood, protein, mucus, and calcium oxalate crystals; the only documentation was that urine results were sent to the ARNP, without clear evidence of timely practitioner notification consistent with facility expectations. A third resident with idiopathic gout had multiple abnormal lab values (low RBC, Hgb, HCT; elevated Hemoglobin A1c and BUN) reported on 3/5/26, with a nursing note the next day stating results were sent to the physician. Subsequent labs on 3/7/26 again showed abnormal BUN and hematologic values, but the daily Medicare Managed Care note section for new labs was left blank, and there was no documentation that the physician was notified of these later abnormal results. Interviews with the DON, RN Unit Manager, and an LPN confirmed that staff are expected to notify practitioners of abnormal results as soon as possible and document this in the medical record, which was not consistently done for these residents.
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