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GOSHEN HOSPITAL 200 HIGH PARK AVE GOSHEN, IN 46526 Jan. 3, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based upon document review and interview, the facility failed to ensure all nursing staff notified the responsible medical provider of critical lab results for 1 of 10 MR (Medical Records) reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Critical Test Results - Receiving and Documenting (approved 7-19) indicated the following: "The following documentation must be included for each critical test result: The result will be called as soon as it is available..." and the policy/procedure included an image of the section in the electronic MR titled Critical Values Reporting where the Registered Nurse must document the Physician notification including the name of the provider, date and time notified, and the response (Acknowledged Value/Result, No New Orders Received, Orders Received, Read Back and Verified, Other).

2. During an interview on 1-2-2020 at 1440 hours, the Clinical Analyst A8 indicated critical lab results are called by lab personnel to the attending or bedside Nurse, the responsible Nurse is required to call a provider and report the abnormal results, and there is a place in the MR to document the MD and/or Allied Health Provider notification.

3. Review of the MR for Patient #3 indicated on 10-19-19 at 0538 hours a Critical Troponin lab test result of 4.05 ng/mL (normal range 0.00 - 0.10 nanograms/milliliter) was called to Registered Nurse N16 and no MR documentation indicated a medical provider was contacted and notified of the abnormal test result.

4. During an interview on 1-3-2020 at 1045 hours, staff A8 confirmed the MR for Patient #3 lacked documentation indicating a Physician or medical provider was called on 10-20-19 around 0540 hours or afterwards and notified of the abnormal Troponin lab value.