Failure to Notify Physician of Critical Lab Results and Document Communication
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of critical laboratory results and to document such notification, as required by facility policy. The facility’s Significant Condition Change and Notification policy required licensed nurses to immediately contact the medical practitioner for emergencies, including abnormal lab values, and to document each attempt to notify the practitioner and the resident’s representative. The Charting and Documentation policy further required staff to document the date and time specimens were obtained and the date and time the physician was notified of lab results. Despite these policies, the medical record for one resident contained no documentation that the physician or family were notified of critical lab findings. The resident was admitted with multiple significant diagnoses, including type 2 diabetes mellitus, heart failure, essential HTN, hypokalemia, hyperlipidemia, and chronic kidney disease stage 3. Admission orders included a CBC, CMP, TSH, BNP, and valproic acid level. A lab report collected several days after admission showed critically low hemoglobin of 5.1 g/dL and hematocrit of 18.7%, both flagged in the critical range. The lab report bore an illegible signature on the final page without a date, and there was no documentation in the resident’s chart that the physician or family had been notified of these critical results, nor any indication in subsequent physician notes that the labs had been reviewed. Over the following months, multiple progress notes by the dietician documented that no labs were located in the electronic medical record, and physician notes on several visits showed no documentation of lab review. Eventually, nursing notes documented that the resident was acting outside baseline with low blood pressure, and the family requested transfer to the hospital, where emergency department labs again showed severely abnormal hemoglobin and hematocrit values. Interviews with RN staff, the Medical Director, the DON, and the Administrator confirmed that nurses were responsible for monitoring lab results, that the lab should call the facility with critical values, and that staff were expected to notify the physician and document this notification. The Medical Director stated she had not been informed of the critical results, the signature on the lab report was not hers, and there was no record of staff notification, confirming that the facility failed to follow its own policies for critical lab result communication and documentation.
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