HospitalInspections.org

Based on record review and interview staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse and Charge Nurse were unable to be reached as per policy; and staff failed to document who was notified of the critical lab results and the time they were notified in 1 of 10 patient critical lab values reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse and Charge Nurse were unable to be reached as per policy. See tag A-0582.

Staff failed to document who was notified of the critical lab results and the time they were notified. See tag A-0582.

Based on record review and interview staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse was unable to be reached as per policy and staff failed to document who was notified of the critical lab results and the time they were notified in 1 of 10 patient critical lab values reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Critical Test Results Communication Policy" last revised 02/23/2022 revealed the following:
-Critical Results and Values: "A test result with an abnormal finding that may represent a life-threatening situation. These values/interpretations require timely notification to the provider to ensure appropriate care for the patient."
- "I. Diagnostic/testing departments will call critical results/tests directly to the ordering/covering provider or to a responsible licensed caregiver..."

Review of policy titled, "...Laboratory Policy: Critical Result Reporting (no date)" revealed the following:
- "Responsible Licensed Caregiver: The licensed practitioner who will assume responsibility for acting upon the critical result or test. This includes: Physician, Physicians Assistants, Nurse Practitioners, Advanced Practice Nurse Prescribers, or health care professionals that have authority to write orders within their credentials..."
- "Authorized Personnel: These personnel can take the verbal communication of critical tests or values from the laboratory and will notify the appropriate Responsible Licensed Caregiver. This includes:...Registered Nurses (RN)..."
- "The critical value/test notification...has been designed to ensure timely communication of critical values and test to an authorized personnel or responsible, licensed caregiver. Every attempt will be made to provide notification as soon as the result is available in the laboratory..."
- "Critical Results for Inpatient and Emergency Department (ED)/Urgent Care Patients...A. Results will be communicated to authorized personnel who are accountable for communication to the responsible licensed caregiver or directly to the responsible licensed caregiver. 1. In the event the authorized personnel assigned to the patient or the responsible licensed caregiver are unavailable, the value may be given to another authorized personnel or responsible licensed caregiver."
- "B. When contact cannot be established with an authorized personnel or responsible licensed caregiver, repeat the call...C. If successful contact cannot be established after this repeat call or authorized personnel/responsible licensed caregiver will not take the result, communicate the result to the on-call nurse/house supervisor/manager. D. If successful contact cannot be established with the nurse/house supervisor after multiple attempts (three), notify the on-call physician for that department...E. If successful contact cannot be established with the on-call hospitalist or they will not take the result, notify the hospital department chair/medical director for help identifying the right clinician who can triage the issue to the ED or another clinical environment. F. If the department chair is not available, escalate to the VPMA (Vice President of Medical Affairs) and/or Chief of Staff of the hospital for help identifying the right clinician who can triage the issue to the ED, or another clinical environment."
- "Documentation of Notification: A. Documentation of Critical Result...Notification in the...Medical Record: 1. Records must show prompt notification of a critical value or test to the appropriate, authorized personnel or responsible licensed caregiver. 2. All attempts for notification will be documented. 3. The documentation must be placed on the critical result that is being communicated..."

Review of Pt #1's Critical Care physician progress notes from 05/24/2024, revealed that Pt #1 was a 82 year old who "presented to the hospital on 05/09/2024 after being found down at his home with confusion. (Pt #1) was diagnosed with a UTI (urinary tract infection) and obstructive uropathy (blockage of urinary flow) causing acute kidney injury...Patient was reportedly doing ok this AM (05/11/24) and actually had a sitter d/t (due to) his confusion. (Pt #1) was sleeping when he was found to be unarousable and pulseless. A code was called. When the medical team arrive patient was in asystole (no pulse)...prolonged code lasting 40 minutes...Called lab during the code as no morning BMP (Basic Metabolic Panel) had resulted and were told K (Potassium) was 6.5 (normal 3.5-5.1). Aggressively treated the K. Intubated. Eventually achieved ROSC (return of spontaneous circulation--pulse) and transferred to ICU (Intensive Care Unit)."

Review of Pt #1's Adverse Event reported on 05/11/2024 at 1:16 PM revealed on Medical Surgical floor 7 East, "Patient was located in room 7201, overhead page received for a medical emergency at approximately 1030 this morning...Pt was coded (received cardiopulmonary resuscitation--CPR) and ROSC (return of spontaneous circulation--pulse) at approximately 1120. Per Dr...at bedside pt had noted critical potassium in addition to creatinine noted from morning labs...Delay in lab results resulting in sentinel event, results not received till code was in progress."

Review of Pt #1's Laboratory Downtime Requisition form revealed Labs ordered for a Metabolic Panel (includes Potassium) to be drawn "Next AM" (routine) on 05/11/2024 at 6:00 AM. Lab collection Date and Time on the form is blank.

Review of Pt #1's 05/11/2024 (6:00 AM) Lab results revealed a Potassium of 6.5 (normal 3.5-5.1) "Completed" on 05/11/2024 at 10:42 AM. Review of the "Comments" on the Lab results revealed that in regard to the "Critical K (potassium) result," staff "Tried calling 3 times-No answer." There was no documentation of who was called and the time of each call as per policy.

Per interview with Lab Manager D on 06/06/2024 beginning at 3:15 PM, Manager D stated that for inpatient critical results, staff do not contact the Provider (Responsible Licensed Caregiver) because they do not have a Volcera (communication device carried by RNs) and are harder to get in touch with. Manager D stated that Lab staff call the RN's Volcera 3 times and if they do not answer, Lab staff would call the Charge Nurse.

Per interview with Lab Director E and Manager D on 06/11/2024 at 1010 AM, Manager D stated that Lab G did not follow the critical results reporting process as per policy beyond contacting the Charge RN.