Failure to Document Nursing Response to Critical Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident with a critical laboratory result. A progress note for this resident documented a critical CO2 value of 42 (reference range 21–31) and stated that the NP and DON were informed and that the resident was stable at that time. A subsequent note recorded that the night nurse (LVN A) reported sending the results to the NP and was awaiting a response. However, there was no further documentation by LVN A describing his assessment of the resident, any follow-up actions taken, or additional communication with the NP beyond this brief entry. Record review showed there was no change of condition assessment completed in response to the critical CO2 lab value. LVN B reported in interview that she called the NP around breakfast time regarding the critical lab and that the NP did not provide new orders, but she acknowledged she did not enter a progress note and stated she must have forgotten to document the contact and outcome. LVN A, in a telephone interview, did not remember details about receiving the critical lab or whether he wrote any notes. The DON stated that LVN A told him he had assessed the resident, found her stable, and texted the NP and the DON, but acknowledged he did not document these actions. These omissions were inconsistent with the facility’s Change of Condition Notification policy, which requires licensed nurses to document the date, time, and details of the incident and assessment, the time and method of physician contact, the response and any orders, family notification, care plan updates, and inclusion of the incident in the 24-hour report.
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