State Findings:
On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility’s failure to report results of laboratory data to the ordering practitioner for resident #10, which indicated the need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/17/20, the resident was started on an antibiotic for a urinary tract infection. The results of the culture and sensitivity revealed that the organism causing the infection, Proteus Mirabilis, was not sensitive to the antibiotic the resident was receiving. The physician was not notified of the results of the urine culture and sensitivity.
Resident #10 was hospitalized on [DATE] with [CONDITION(S)], and subsequently passed away on 03/26/20. The immediate cause for death was septic shock due to Proteus Mirabilis.
On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health.
On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician.
On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted.
On 01/25/21 at 2:02 p.m., physician #1 was interviewed regarding lab results. He stated that he expected to be made aware of abnormal lab results. He stated that the lab company will call the facility and the physician with critical results, but culture and sensitivity results were not critical labs. Physician #1 stated the facility did not notify him of the culture and sensitivity results for resident #10.
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Personal Note from NHA-Advocates
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