Based on record review, staff interview, and facility policy review, the facility failed to notify the Physician of critical lab values for one (1) of four (4) resident's lab values reviewed, Resident #58. Labs were ordered for Resident #58 on [DATE], and drawn on [DATE], due to the resident's decline in mental/physical function. On [DATE], at approximately 1:05 AM, Registered Nurse (RN) #2 was notified per phone, by the laboratory, of critical values for Resident #58. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). …
D · No harm, potential for more than minimal, isolatedAugust 3, 2026
Based on record review, staff interviews, and facility policy review the facility failed to ensure the physician was notified of resident lab results which caused a delay of treatment for one (1) of three (3) sampled residents reviewed. Resident #1 Findings include: Review of facility policy titled Change In Condition Policy and Procedure, revealed Purpose: To provide guidance to licensed nurses on follow-up documentation post-acute episode, antibiotic therapy, incident and accident, change in condition, hospital return, etc.Procedure.a. Acute episodes/Change in Condition/hospital return: i. Notify physician and document results of physician contact . …
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