HospitalInspections.org

Based on review of hospital policy, medical record review, and interview, the hospital failed to report critical laboratory findings in a timely manner for 1 of 3 (Patient #3) sampled patients reviewed.

The findings included:

1. Review of hospital policy, "Critical Tests and Alert Values" documented, "Purpose: A process exists where by all laboratory results that fall outside of defined limits are communicated to the responsible licensed caregiver or health professional that can take definitive action... Definitions...Critical Tests- A test defined by the testing department to be critical in nature and is reported to the licensed caregiver or physician, regardless of the result. The following tests are considered critical tests and monitored for timeliness, CBC [Complete Blood Count], Comp [Comprehensive] Metabolic Profile...Procedure: alert values will be called by the lab personal to the appropriate caregiver within 15 minutes of finalizing the test value...Goals are as follows: Lab to nursing, 15 minutes, Nursing to MD, 30 minutes..."

Medical record review for Patient #3 documented the patient was admitted on 9/5/2025 at 9:49 AM to the emergency department with chief complaint of intermittent worsening Altered Mental Status, Lower Extremity Edema, and Low Blood Pressure. A CBC was ordered at 10:00 AM and collected at 10:39 AM. The critical lab result was called back to Registered Nurse (RN) at 2:59 PM (4 hours and 20 minutes) by laboratory personnel. The critical results were:Hemoglobin (a protein in the red blood that carries oxygen from the lungs to the body's tissues and transports carbon dioxide back to the lungs) 5.2 , reference range, 12.0 to 16.0. The Hematocrit (measures the percentage of red blood cells in your body) was 16.2., reference range, 36.0 to 46.0. There was no documentation the emergency department was notified of the critical lab results until 2:59 PM.

In an interview on 9/29/2025 at 1:00 PM, the Director of Lab Services provided the policy and procedure for critical tests and alert values. The policy documented "...lab to nursing 15 minutes, nursing to MD [Medical Doctor] 30 minutes...". When asked about the four-hour delay for Patient #3's lab, the Director of Lab Services stated, "...that is not a reasonable amount of time...".

In a telephone interview on 9/30/2025 at 11:00 AM, Physician #1 stated "...I remember the sister expressing concern of her discharge. I did a rectal exam on the patient and re-ordered her lab work. I was surprised at it because she did not present with classic pallor and basically looked good. I reversed my course of treatment and cancelled her discharge home and had her admitted to the hospital. I don't know why her lab was not reported to me..." Physician #1 stated that a delay such as that is not normal and the lab normally calls the ED desk and then that call is given to the Charge Nurse or another Registered Nurse (RN), who then notifies the physician.

In an interview on 9/30/2025 at 11:19 AM the Lab Director stated, "there is no explanation for the delay in reporting the critical Hemoglobin and Hematocrit".