Failure to Timely Notify Physician of Abnormal Lab Result
Penalty
Summary
The facility failed to ensure timely physician notification of an abnormal laboratory result for one resident, as required by its policy on changes in a resident's condition. The facility policy dated 2/02/26 stated that the resident, attending physician, and resident representative would be promptly notified of changes in the resident's medical or mental condition or status. Resident R2 was admitted on 1/22/22 with diagnoses including Alzheimer's disease, atrial flutter, muscle weakness, and high blood pressure. A lab report in the resident's clinical record showed that a specimen collected on 11/26/25, received and reported on 11/27/25, revealed an abnormal potassium level. Progress notes documented that the abnormal potassium findings were not reviewed with the physician until 12/11/25, at which time the resident was transferred to the hospital related to the potassium level obtained on 11/26/25. The record lacked evidence that the physician was notified in a timely manner of the abnormal potassium result, despite the facility's policy requiring prompt notification of changes in condition. During an interview on 3/04/26, the Assistant Director of Nursing confirmed that there was no evidence of timely physician notification and acknowledged the lack of immediate notification regarding the abnormal potassium level from 11/26/25.
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