Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner of abnormal laboratory results for a resident. The resident was admitted with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, and had severe cognitive impairment and dependence on staff for activities of daily living, as well as an indwelling catheter. A physician order for a urinalysis was dated 06/11/25, and a urine culture completed on 06/14/25 showed a positive result for Methicillin Resistant Staphylococcal Aureus (MRSA). Despite the abnormal culture result on 06/14/25, review of the medical record showed no documentation that the physician was notified of these results until 06/27/25, when an order was obtained for Macrobid 100 mg by mouth twice daily for seven days for a urinary tract infection. During an interview, the ADON confirmed that the medical record did not contain documentation supporting timely notification of the physician regarding the abnormal lab results. The facility’s policy on lab and diagnostic test results required nursing staff to review results upon receipt, determine the urgency of communication based on the seriousness of abnormalities and the resident’s condition, and notify the physician using various possible communication methods.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.