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⭒ Violation of the Month Archive

Resident Dies After Facility Fails to Notify His Doctorof Critical Laboratory Results

On April 19, 2013, a 75-year old resident died after Glenwood Gardens SNF, a skilled nursing facility in Bakersfield, failed to notify his doctor of critical laboratory results.

On April 17, 2013, the resident’s doctor ordered a complete blood count and requested to be notified as soon as the results were received. The next day the facility received the results, which showed several critical laboratory values requiring immediate attention. However, instead of notifying the physician immediately as he requested and was required by the facility policy, a nurse placed them on a clipboard for the next routine visit. No one reviewed the results.

The next morning, on April 19, 2013, the resident was found unresponsive and sent to the hospital, where he died in the emergency room within a few hours of arrival. Blood tests taken upon his arrival showed he was critically ill. The hospital diagnoses included septic shock, renal insufficiency and anemia.

The Director of Nursing (DON) for Glenwood Gardens stated that the nursing staff was not even aware of the critical laboratory results until the resident’s physician came to the facility on April 19, 2013, after the resident’s death, to review the records. He showed the DON the critical laboratory results that had been left on the clipboard.

The resident’s physician reported he had a meeting with the DON and other nurses at the facility on April 18, 2013, before the resident’s critical laboratory results were received, to advise them to call him for all laboratory results because he had been having problems getting notified. The physician stated, “I told them you guys are going to kill somebody.”

After the warning from the resident’s physician, the facility staff did not change their practice.

Violation of the Month Archive