HospitalInspections.org

Based on review of policies and procedures, medical record (MR) and interview, it was determined the hospital failed to ensure nursing staff followed physician orders and hospital policy and notified the physician of abnormal laboratory results.

This affected MR # 5, 1 of 1 record reviewed with with abnormal lab results and had the potential to affect all patients treated at the hospital.

Findings include:

Subject: Orders for Care and Treatment of the Patient
PolicyStatID: 1853446
Last Revised: 10/6/2015

Purpose:

"...guideline to outline...who may give/receive orders and how orders are documented.

Procedure:

1. Type of Orders

1. Written:

a. Direct transcription by the author.

111. Individuals Authorized to Receive/Execute Orders within their scope of practice include...

1. Registered Nurses (RN)

IV. Documentation

1. Written, i.e. direct transcription by the author. Orders must be written and authenticated by signature, date and time by the person giving the order.

7. Nursing:
a. When physician orders have been transcribed, an RN must recheck the orders to be sure they are transcribed correctly. The RN checking the orders shall sign name, title, date and time.
b. The 11-7 shift has the responsibility for reviewing orders for the previous 24 hours... "

Subject: Notification of the Physician
PolicyStatID: 2161033
Last Revised: 3/2/2016

Purpose:
To describe the process for when and how to notify a physician.

"Policy:

B. Significant changes which need to be immediately brought to the physician's attention and documented...in the patient's medical record, include but are not limited to:

3. Abnormal recent lab values that have not been noted by the M.D. (medical doctor).

Procedure:

4. Review the most recent M.D. Progress Note...recent medications...and any recent lab/radiology results.

C. Call the physician...Wait no longer than 10 minutes between attempts if the situation is urgent...no longer than 30 minutes between attempts if the situation is routine.

D. Document the event...and the physician notification in the patient's medical record..."


MR. # 5 was admitted to the rehabilitation unit on 9/9/15 with diagnoses including Traumatic Subchorionic Bleed and Status Post Fall.

Medical record review included a handwritten physicians' order dated 9/22/15 at 1:37 PM for a BMP (basic metabolic profile)-call with abnormals and CBC (complete blood count)-call with abnormals.

Medical record review revealed the BMP and CBC were collected at 3:40 PM, completed and results released at 4:23 PM on 9/22/15.

Review of the BMP results revealed the following abnormal results: Sodium 132; reference range 135-148 mmol/ L (millimole per liter), BUN (blood urea nitrogen) 126 H (high); reference range 7-19 mg (milligram)/dL (milligram per deciliter) Creatinine-4.77 H ; reference range 0.48-1.07 mg/dL; eGFR (estimated glomulerular filtration rate) 9 L (low); reference range 60-600 mL/min (milliliter per minute)/1.73m2 (body surface area), Glucose 139 H, reference range 65-110 mg/dL; Calcium 8.5 L; reference range 8.7-10.5 mg/dL.

Review of the CBC results revealed the following abnormal results: WBC (white blood count) 36.2 H; reference range 4.1-10.5 K/mm3 (thousands per cubic millimeter), RBC 3.45 L; reference range 3.80-4.92 million/mm3 (millions per cubic millimeter), HGB (hemoglobin) L; reference range 11.9-15.1 g/dL (grams/deciliter), HCT (hematocrit) 30.6 L; reference range 35.0-44.2 %.

Record review revealed a Licensed Practical Nurse (LPN) verified the physician order on 9/22/15 at 2:00 PM. On 9/22/15 at 11:30 PM, a Registered Nurse 'rechecked' and signed the order entry as accurate. The 24 hour chart check was 'reviewed' by 3rd shift nursing staff on 9/23/16 at 12:00 AM, confirming completion of all physician orders written over the past 24 hours.

Review of nursing staff documentation did not include physician notification for the CBC and BMP abnormal results following release of results on 9/22/15 at 4:23 PM.

On 9/23/15 at 9:59 AM, documentation by the hospital medical Certified Registered Nurse Practitioner included " abnormal labs not called yesterday as ordered. I was notified at 9:05 AM today....Acute Renal Failure, check urine lytes, hold nephrotoxics, start IVF's (intravenous fluids, US (ultrasound) Renal, ? dehydration with poor intake, Leukocytosis, [check] UA...CXR (urinalysis...chest x-ray)...will start Levoflox (Levofloxacin)..."

Further review of medical record documentation revealed MR # 5 was transferred to the medical floor on 9/23/15 followed by an intensive care unit transfer on 9/24/15 .

In an interview on 9/14/16 at 1:30 PM, Employee Identifier (EI) # 1, Lead Outcomes Manager confirmed nursing staff failed to follow physician's orders and notify the physician of abnormal lab results on 9/22/15.