Failure to Promptly Report Critical Lab Result and Change in Condition
Summary
A deficiency occurred when the facility failed to promptly report a critical laboratory result to the ordering practitioner for a resident with multiple complex medical conditions, including cancer, end-stage renal disease requiring hemodialysis, heart failure, and acute kidney failure. The resident had a critical low blood glucose value of 42, which was identified after blood was drawn at dialysis. The laboratory notified the facility of this result, but the nurse on duty was unable to reach the physician and only sent a text message, receiving no response. No further escalation was attempted, and the Medical Director was not contacted as required by facility policy. The resident had exhibited a change in condition, including confusion and cold extremities, on the evening prior to being found unresponsive. Staff had difficulty obtaining vital signs, particularly oxygen saturation, and these issues were reported among the care team. Despite these signs and the critical lab value, there was no documented evidence that the physician was promptly notified or that additional monitoring or interventions were initiated in response to the abnormal findings. The resident was later found unresponsive and was pronounced deceased by EMS. Interviews and record reviews revealed that staff were aware of the abnormal findings and the facility's policies required immediate physician notification for critical lab results and changes in condition. However, the nurse did not follow the escalation protocol when the physician could not be reached, and there was a lack of timely and effective communication among the care team regarding the resident's deteriorating status. The failure to report the critical lab result and adequately respond to the change in condition constituted the identified deficiency.
Removal Plan
- RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.
- RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition. During this education, the DON/designee reviewed the Handoff Communication policy to clarify expectations of correctly rounding residents at end and beginning of the shift.
- CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.
- LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety.
- Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
- Inservice training was provided by DON/designee with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.
- A root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.
- The NHA will oversee corrective actions and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action.
- Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- All residents were identified to be at risk for the identified deficient practice. A random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. A random audit of all vital signs taken for all residents completed by DON or designee showed that there was a total of 8 residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. A random audit of all vital signs taken for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents: BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified; BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified; PR parameter for 1 resident that is not on any ACE, ARBs, Calcium or beta blocker was added after physician notification; 2 resident triggered as abnormal but after review is within normal limits of resident range of BP; 3 residents had over 100 PR but have medications administered.
- Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs.
- The ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
- The ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
- A random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
- RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition.
- CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs.
- LVN B was provided 1:1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.
- Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
- Inservice training was provided by DON/designee with all LNs. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple medical conditions experienced a change of condition for which a physician ordered a urinalysis. Review of the electronic record showed no urinalysis results for the period reviewed, despite the order and concurrent initiation of antibiotics. The ADON and DON both confirmed they could not locate the lab results in the EHR and acknowledged that staff should have obtained the specimen or documented any inability to do so. The ADM stated her expectation that clinical staff follow physician orders and document unsuccessful attempts, noting that failure to obtain ordered labs can prevent the physician from addressing potential health issues.
Failure to Obtain Ordered UA with C&S: A resident with an indwelling foley catheter and a history of UTI had hematuria noted in the catheter, and the MD ordered a UA with C&S to rule out UTI. Record review and staff interviews showed the specimen was not collected as ordered and the lab was not notified through the lab software, despite the facility’s process requiring the nurse to obtain the specimen and arrange lab pick-up.
Failure to promptly notify the physician of abnormal lab results occurred for a resident with DM, dysphagia, and hypokalemia who was receiving potassium chloride and spironolactone. A CMP showed elevated K+, BUN, creatinine, and reduced eGFR, but nursing documentation did not show physician notification. The resident later developed increased confusion and a critically high K+ level, and the physician was then notified and ordered transfer to the ER.
Two residents with ESRD, heart failure, acute kidney failure, and type II DM had multiple critical lab values (elevated creatinine and BUN) that were reported by the lab to nursing staff but were not documented as promptly communicated to a provider, and there was no documentation that an RN supervisor assessment was completed as required by policy. Nursing notes lacked entries showing provider notification, times of contact, or new orders at the time critical results were received or later reviewed, and provider documentation of these critical values occurred one or more days after the lab reports. An RN reported signing off lab results as reviewed in the EHR to clear alerts, not realizing only providers should do so, and could not recall specific notifications made, while leadership interviews confirmed expectations for immediate provider notification, RN supervisor follow-up assessment, and complete documentation that were not met in these cases.
A resident with complex cardiac and respiratory conditions had diuretics discontinued by cardiology and a BNP test ordered. The resulting BNP level was critically elevated and flagged as "High High." An LPN received the result, sent it to the physician via secure messaging, did not obtain any orders, was unsure if a phone call was successfully made, and did not notify the cardiologist. The physician later stated he did not see the message until the next morning, did not receive a call from the facility, and did not issue orders. Leadership and other nursing staff reported that critical labs are expected to be called directly to the physician, consistent with the facility’s change-in-condition policy, but no separate lab policy was produced.
A resident with a history of stroke and communication/swallowing difficulties experienced a change in respiratory condition, prompting a physician to order blood work and a urinalysis. The UA later showed elevated WBCs and significant gram-negative bacterial growth consistent with a UTI, but there was no documentation that the physician or NP was notified and no orders for UTI treatment were found. The resident was later sent to the hospital for mental status changes and returned with diagnoses including pneumonia and UTI. The DON and physician confirmed the lack of notification, and leadership acknowledged there was no formal policy for notifying practitioners of abnormal UA results, though it was considered standard practice.
Failure to Obtain Ordered Urinalysis and Document Results
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain laboratory services as ordered and to have results available for review for one resident. A male resident with severe cognitive impairment, a history of acute respiratory failure with hypoxia, dysarthria following stroke, and Alzheimer's disease had a physician order for a urinalysis (UA) on 02/25/2026 following a change of condition. Record review from 02/25/2026 through 04/30/2026 showed no UA results in the electronic clinical record. The resident’s medical record also reflected standing orders for periodic blood work, including CBC, CMP, lipid panel, valproic acid level every six months, and Hgb and A1C every three months, but the cited deficiency focused on the missing UA ordered on 02/25/2026. During interviews, the ADON reported she was unable to locate the UA results for the resident and stated that the UA "had to be done" because the physician had ordered antibiotics. She also stated that if staff had been unsuccessful in obtaining a urine sample, this should have been documented. The DON confirmed she could not find the UA results in the EHR and stated that, because the physician ordered the UA, staff should have obtained the lab. The DON noted that staff were aware of the change of condition, contacted the physician, and that antibiotics were ordered and administered while the resident’s vital signs remained within normal limits. The ADM stated her expectation that clinical staff follow physician orders and document if a sample cannot be obtained, and she acknowledged that failure to obtain ordered labs could lead to potential health issues that the physician would not be able to address.
Failure to Obtain Ordered UA with C&S
Penalty
Summary
The facility failed to ensure a laboratory service was provided as ordered for one resident with an indwelling urinary/foley catheter and diagnoses including neuromuscular dysfunction of the bladder and urinary tract infection. The resident was observed alert and resting in bed with the catheter in place, and stated the catheter had been placed for safety reasons because he could not stand up to go to the restroom on his own and that he often got urinary tract infections. The resident’s record showed that after hematuria was noted in the foley catheter, the physician was notified and ordered a flush and a UA with C&S to rule out UTI. Record review showed the UA with C&S was ordered, but there was no documented evidence that the specimen was collected as ordered. There was also no documentation that the laboratory was notified of the new physician order. During interviews, an LVN verified the process was not followed and confirmed there was no order placed in the laboratory software for the UA with C&S. The DON stated the licensed nurse should have collected the urine specimen right away, placed it in the specimen refrigerator, and notified the laboratory for pick up, but this was not done.
Failure to Notify Physician of Abnormal Potassium Result
Penalty
Summary
Timely physician notification of clinically significant abnormal laboratory results was not ensured for one resident. Resident 87 was admitted with diagnoses including diabetes, dysphagia, and hypokalemia, and had moderately impaired cognition with a BIMS score of 12. Physician orders included potassium chloride 20 mEq by mouth twice daily and spironolactone 25 mg daily. A CMP obtained revealed abnormal values including elevated BUN, creatinine, reduced eGFR, and a potassium level of 5.2 mmol/L, with the potassium elevation occurring while the resident was receiving potassium-increasing medications. The clinical record did not show that licensed nursing staff notified the physician of the abnormal laboratory results after they were obtained. A nursing progress note later documented that the resident's daughter reported the resident was tired, not herself, and more confused, and the RN supervisor was notified, but there was still no documented evidence that the physician had been informed of the earlier abnormal lab findings or the change in condition. The resident continued to receive potassium supplementation and spironolactone as ordered after the abnormal potassium result was identified. A CRNP later evaluated the resident and ordered repeat laboratory testing. When repeat labs were drawn, the potassium level was critically high at 7.4 mmol/L, and the resident had increased confusion and complaints of crushing pain at the base of the neck. The physician was then notified and ordered immediate transfer to the emergency room. Hospital records showed the resident was admitted with hyperkalemia.
Failure to Promptly Report and Document Critical Lab Results and RN Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that abnormal and critical laboratory results were promptly reported to providers and followed by an RN supervisor assessment, as required by facility policy. For one resident with end stage renal disease, dependence on hemodialysis, and type II diabetes mellitus, lab work showed a critically high creatinine level of 4.24, reported to the facility in the evening and later reviewed by an RN the following morning. Nursing notes from the date of the lab and the following day did not document that the critical creatinine value was reported to a provider or that an RN supervisor assessed the resident. A provider note from that day did not reference the critical value or any notification, and the provider did not document review of the critical result until two days later. For another resident with heart failure, acute kidney failure, and type II diabetes mellitus, multiple critically high BUN levels were reported over several dates, but there was no documentation that these critical values were promptly communicated to a provider or that an RN supervisor assessment occurred at the time of each result. A critically high BUN of 73 was reported to an RN, but there were no nursing notes for that day and no documentation of provider notification when the result was received or when later reviewed by another RN; the provider did not document review of this lab until two days later. Subsequent critical BUN values of 70, 80, and 75 were each reported to nursing staff and later reviewed by the same RN, yet nursing notes over the corresponding periods did not show timely provider notification or RN supervisor assessment, and provider documentation of these critical values occurred one day later in each instance. Interviews further clarified the actions and inactions contributing to the deficiency. The RN who reviewed many of the critical results stated she was aware of the critical values and believed she had reported them but could not recall to whom, at what time, or whether new orders were obtained, and she was unaware that policy required an RN supervisor assessment to accompany abnormal lab reporting. She also reported that she had been signing off lab results as reviewed in the electronic record to clear them from her homepage, not realizing that only providers should sign off results under the results tab. The Medical Director stated that RNs receiving critical values should immediately notify a provider and document the provider’s name, time of notification, and any new orders, and that only providers should sign off lab work as reviewed. The DON stated that the RNs involved should have ensured immediate provider notification and complete documentation of the notification details for the critical lab results, and acknowledged uncertainty about who should sign off lab work as reviewed and about the specifics of the abnormal lab and physician notification policies.
Failure to Timely Notify Physician of Critical BNP Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a physician of a critical laboratory value for one resident. The resident was admitted with multiple diagnoses including acute on chronic systolic congestive heart failure, COPD, chronic respiratory failure with hypoxia, peripheral vascular disease, obesity class 2, difficulty walking, anxiety, major depressive disorder, osteoarthritis, hypo-osmolality, and hyponatremia. On 4/3/26, cardiology discontinued the resident’s Lasix and Bumex and ordered a complete metabolic panel and BNP test, with instructions for an office follow-up in one week. The BNP result, received by the facility’s lab on 4/9/26 at 9:06 AM, was 761, flagged as a “High High” (HH) critical value, with a normal range of 1–100. A progress note documented that late on 4/9/26, an LPN notified the physician via a secure messaging application. In interview, the LPN stated she received the lab value while on break, sent a secure message to the physician after seeing he was active on the application, did not receive any orders in response, and was unsure whether she successfully attempted a phone call; she also did not notify the cardiologist who ordered the test. The physician reported he received the critical lab notification via secure messaging at 11:24 PM on 4/9/26 but did not see the lab until the next morning and did not respond with any orders, and he stated he did not receive a call from the facility about the critical lab. The regional clinical nurse and DON both stated that critical labs should always be called to the physician, and other LPNs described their usual practice as immediately calling, faxing, and/or using secure messaging for critical labs. The facility’s “Change in Condition” policy required notifying the attending or on-call physician when there is a need to significantly alter medical treatment or a significant change in condition; a specific lab policy was requested but not provided.
Failure to Notify Practitioner of Abnormal Urinalysis Result
Penalty
Summary
The deficiency involves the facility’s failure to notify the ordering practitioner of an abnormal urinalysis result for one resident. The resident was admitted with a history of stroke, resulting in weakness or paralysis on one side of the body, and had difficulty swallowing and speaking. An Interact change-of-condition form documented a change in the resident’s respiratory condition, and the physician ordered blood work and a urinalysis. The urinalysis report later showed elevated white blood cells and more than 100,000 CFU/ml of gram-negative bacteria, indicating a positive result for a urinary tract infection. However, there was no documentation that the physician or nurse practitioner was notified of these abnormal results, and there were no orders showing that the resident was treated for a UTI at that time. Subsequently, the resident was transferred to the hospital for changes in mental status and later returned with diagnoses of pneumonia and UTI. During interviews, the DON confirmed that the urinalysis results were positive for a UTI and acknowledged there was no documentation of physician notification or antibiotic treatment. The physician also confirmed they had not been notified of the abnormal urinalysis results and stated that, although there were no other signs of a UTI besides the urinalysis, they should have been informed. The NHA and DON reported that the facility did not have a specific policy for notifying a physician or extender of an abnormal urinalysis result, but considered such notification to be standard practice.
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