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Based on review of records and interview, the facility failed to ensure that nursing staff documented, per hospital policy, the physician notification of critical lab values for blood calcium levels in 4 out of 4 patient charts reviewed (Patient #3, #5, #6, and #7).

On 10-6-2021, a review of Patient #3's chart was made. The patient was seen in the Emergency Department on 9-8-2020. Blood tests were ordered on 9-8-2020 at 4:50 PM. The chart showed that the laboratory notified Staff #14 of a critical low lab result for the blood calcium level. Review of the nursing documentation showed the chart did not include information about Staff #14 notifying the ordering practitioner of the critical lab value. Review of physician documentation did not include information about being notified of a critical lab value.

A current list of critical lab values reported between 9-22-2021 and 10-6-2021 was requested and received from the hospital lab. Patient #5 had a critical low calcium level on 9/23/2021. Patient #6 had a critical low calcium level on 9-27-2021. Patient #7 had a critical low calcium level on 10-3-2021. Review of Patients #5, #6, and #7 charts showed that the nursing staff notified of the critical lab values did not include the information regarding the notification of the physician in their charting. The physician charting also did not include information regarding notification of a critical lab value.

Review of Policy Number ADM.00.01.0049, Subject: Notification of Physicians, Including Critical Value Reporting, Revision Date: 10/19, was made on 10-7-2021.

"POLICY:
Licensed nursed/qualified technicians are responsible for notifying physicians regarding vital information, significant events and/or changes in patient status.
...

DOCUMENTATION:
Document in the medical record the assessment of the patient and actions taken, time of physician notification, who was contacted (doctor answering service or office personnel, time call was returned and whether orders were received. (sic) Note if Supervisor, Vice President of Nursing, Chief of Section or Service was contacted if there is a difficulty in notifying the physician.

Laboratory, EKG and Imaging services have established a standardized list of critical values/results that represent life threatening conditions. The Laboratory, EKG or Imaging value/result will be called to the attending or ordering physician, or the appropriate Nursing unit immediately. The value/result will be read back for verification and documented in the patient medical record. Laboratory and all other abnormal reports, x-rays, EKGs, etc. will be reported in the following manner:
1. Immediately, (within 30 minutes of the nurse receiving the result), the nurse will notify the appropriate physician of the critical value/abnormal test result and will ask the physician to repeat the value/test result.
2. The nurse will then document in the nurses notes the date time and name of the physician the value/result was reported to.
3. Any orders that are issued as a result of the critical value/test result should be noted in the nurses' notes and documented in CPOE Physician's order section of the medical record."