The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST ELIZABETH MEDICAL CENTER 2209 GENESEE STREET UTICA, NY 13501 July 21, 2016
VIOLATION: LABORATORY SERVICES Tag No: A0576
Based on findings from document review and interview, the hospital failed to ensure that critical/panic value reporting by laboratory services staff was performed in a safe and consistent manner. The hospital's policy and procedure (P&P) did not include a process to ensure that critical and noncritical laboratory values were correctly reported to providers. This lapse may have resulted in patient harm.

Findings include:

-- Review of Patient #1's Chemistry Results form showed a critical (panic low) value of sodium - 119 mEq/L (normal 136-145 mEq/L) was identified by the laboratory on 7/11/16 at 8:05 am. Staff A (Specimen Processor) notified the outside provider at 8:08 am. (Unable to determine what result(s) were shared with outside provider.)

During interview with Staff A on 7/13/16 at 2:30 pm, he/she indicated when a critical laboratory value appears on his/her computer screen, he/she reports the value to the outside provider.

Patient #1's Chemistry Results form lacked any documentation to verify that the correct laboratory value was reported.

During interview of Staff B (Operations Coordinator) on 7/21/16 at 10:00 am, he/she acknowledged this finding.


-- Review of the hospital's P&P titled "Laboratory Communication of Critical Values, Stats and Other Results," dated 1/19/15, indicated that for any lab results given verbally, the laboratory staff should document the full name of the person taking the results, their credentials, location and read back verification in the computer.

However, per review of the hospital's laboratory "Critical Value Report" for 7/11/16, which lists all critical results called for that day, it did not contain all documentation required for oral notification of a laboratory critical value result.

For example, on 7/11/16 at 6:25 am, Staff C (Specimen Processor) reported a positive MRSA (methicillin resistant staphylococcus aureus) culture for Patient #2. Staff C documented "Nurse" in the field indicating degree/accreditation of the person receiving the result. There was no documentation indicating their credentials (i.e., RN or LPN). On 7/11/16 at 10:44 pm, Staff D (Specimen Processor) reported hemoglobin and hematocrit levels of 6.7 g/dl and 20.3 percent, (normal 12.0-16.0 g/dl and 37.0-47.0 percent) respectively, for Patient #3. Staff D documented the first name and first initial of the last name of the person receiving the result. There was no documentation indicating their last name.

During interview of Staff E (Lab Director) on 7/21/16 at 10:15 am, he/she acknowledged the above findings.


-- Interview of staff revealed they are not clear on their roles and responsibilities in reporting critical and noncritical laboratory values.

For example, interview of Staff A on 7/13/16 at 2:30 pm, revealed he/she gives verbal laboratory results by phone for tests other than critical when asked by the person taking the report. The results may include normal and abnormal results. He/she requires read back verification for only critical results when multiple results are communicated. Staff C (Specimen Processor) revealed during interview on 7/14/16 at 9:10 am, that he/she gives verbal laboratory results by phone for critical results and all abnormal results and requires read back verification for all results given verbally. Staff F (Specimen Processor) revealed during interview on 7/14/16 at 9:40 am, that he/she gives verbal laboratory results by phone for only critical values. If the caller requests additional lab values that are not critical values, he/she would place caller on hold and speak with another staff member who is "more comfortable in the position" to determine action. He/she has been instructed to report only critical values.

Review of the hospital's P&P titled "Laboratory Communication of Critical Values, Stats and Other Results," dated 1/19/15, revealed it does not clearly define the process for staff to follow when reporting laboratory values.

During interview of Staff G (Lab Business Manager) on 7/14/16 at 5:00 pm, he/she acknowledged the above findings.