Abbey Rehabilitation and Nursing Center was cited after failing to “identify and notify the physician of elevated laboratory results.” The resident’s physician noted the resident’s white blood cell count was high, so he ordered another test to be taken. The second test revealed an even higher white blood cell count, but these results were not acted upon until five days later. When the facility finally reviewed the results, the patient needed to be hospitalized.
During an interview with the resident’s nurse practitioner, she stated she was working the day the elevated test results were received, but she was not made aware. She stated she was told by the nurse that the resident’s vitals were stable and removed the PICC (peripherally inserted central catheter) intravenous line. The nurse practitioner said the lab results should’ve been faxed to her office and placed in the resident’s chart. If the labs were elevated, which they were, they should perform a test everyday until the results “were at a baseline or under 10 for the white blood cell count.”
The nurse practitioner indicated to the investigator that she would have her office send her notes on the resident’s condition and would contact the nurse to reorder labs. The investigator reviewed her notes and confirmed that the lab information for the resident was not documented.
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The investigator interviewed a Licensed Practical Nurse who took care of the resident in this citation. He stated that labs get ordered online and then go into the “lab book.” He said he does not fax results to the physician’s office unless they are completely normal. This is contrary to what the nurse practitioner said, because she indicated the results should’ve been faxed to her office and placed in the resident’s chart. The LPN did not fax the abnormal results to the physician’s office, just “called and left a message with the ARNP (advanced registered nurse practitioner) and let the oncoming nurse know that a message was left.”
When a resident has a change in condition, there are a few things that need to be done at this facility:
- Notify the physician resident/resident representative (and case management when indicated) if there is a significant change in condition, regardless of the time of day.
- If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the telephone call, another nurse will make the call.
- Document the nurse’s notes, the time the call was made, and to whom you spoke.
The facility also has a policy for any abnormal lab results. The physician should be made aware of “all critical labs immediately.” If they can’t reach the physician within two hours of receiving the results, they need to contact the facility medical director for further orders.
When families place their loved ones in the care of a nursing home facility, they trust the staff to follow through with policies and procedures. Nursing homes must follow their guidelines in order to ensure each resident’s needs are met. They also much have a clear plan of communication so that a resident’s change in condition can be addressed in a timely manner. In this case, the resident went five days without necessary medical treatment, resulting in “transfer to the hospital.”
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