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ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 Feb. 23, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview, medical record review and a review of hospital documentation, the hospital failed to ensure that all laboratory tests for calcium with critical results were reported to a physician in accordance with approved policies fro 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. Lab results for calcium were posted in the record using used a reference range of 8.6 - 10.3 MG/D (milligram/deciliter), with a critical value being noted at anything at or below 6.4 MG/D. During the patient's stay, critical levels of 5.7 MG/D were noted on 12/13/15 at 3:27 AM.

Hospital policy "Critical Results & Values: Reporting" read, "Laboratory critical values after verification by a licensed laboratory professional are communicated immediately by the laboratory to a physician or licensed member of the healthcare team. This notification must be documented....The individual who is receiving the report from the laboratory must....Notify the physician as appropriate using the read back verification process and document all physician calls."

Regarding the above mentioned critical calcium level of 5.7 MG/D on 12/13/15, there was no evidence in the record of physician notification of the results, as required in policy. A physician's note of 12/13/15 at 8:34 AM read, "Calcium 5.7." This entry was the first evidence that the physician would have been aware of a critically low calcium level. There was no evidence that the physician had been notified of the results in a timely manner. This was not in compliance with the above stated policy.

During an interview of the Risk Manager on 2/23/16 at 5 PM, she confirmed the findings.