Failure to Communicate Critical and STAT Lab Results to Practitioner and Responsible Party
Penalty
Summary
The deficiency involves the facility’s failure to ensure critical abnormal laboratory results were promptly reported to the practitioner and to obtain STAT laboratory tests as ordered. For one resident (Resident D), who had diagnoses including COPD, diabetes, and hypertension and was cognitively impaired requiring maximum assistance, the record showed a history of a recent hospital stay related to a critical low hemoglobin level. After returning to the facility with hemoglobin at non-critical levels, blood was drawn again for diagnostic labs on 7/3/25, and critical lab values were reported to the facility at 2:30 p.m. The medical record, however, lacked documentation that the physician was notified of these critical abnormal lab results, despite facility policy requiring documentation of notification or notification attempts to the medical provider in the electronic medical record when there is a change in condition. The deficiency also includes the facility’s failure to obtain STAT labs and to notify the practitioner and responsible party when labs could not be obtained for another resident (Resident Q). This resident had Alzheimer’s disease with late onset, dementia, severe cognitive impairment, and required assistance with daily care needs. STAT labs were ordered on 11/29/25 due to a change in condition and increased pain complaints, but the lab was unable to send a technician to draw blood, and the record lacked documentation that the physician was notified that the labs could not be obtained or that the resident refused to go to the hospital for labs, as well as lacking documentation of notification of the responsible party. STAT labs were again ordered on 1/22/26, and the record again lacked documentation that the physician was notified when the labs were not obtained. Interviews with nursing staff and the DON confirmed expectations that changes in condition, including labs, should be communicated to the provider and responsible party, and the facility’s written policy required such notifications and documentation in the electronic medical record.
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