Glenwood Gardens SNF
350 Calloway Dr, Building C Bakersfield, CA 93312
Citation Number: 120000453
Citation Date: 02/19/2014
Violation Date: 04/19/2013
Class: A
Penalty: $20,000


F-309 483.25

The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process.

On April 22, 2013 an unannounced visit was made to the facility to investigate an entity-reported incident regarding a resident (Resident 1) who had critical laboratory results but the facility staff failed to notify his physician of the results immediately. The resident was transferred to an acute care hospital and died within a few hours of his arrival to the hospital.

Based on interview and record review, the facility failed to ensure one resident's (Resident 1's) critical laboratory results were reported to the physician. This failure resulted in delay of treatment and ultimately, Resident 1's death.


Resident 1 was a 75-year-old alert and oriented male with a history of cardiac disease, COPD (chronic obstructive pulmonary disease) chronic lung disease that can cause shortness of breath.

On 4/22/13, Resident 1's clinical record was reviewed. Resident 1's physician, on 4/17/13, ordered a Complete Blood Count (CBC, a blood test that indicates anemia and infection) and a Basic Metabolic Panel (BMP, a test that indicates the status of the kidneys) to be done on the following day, 4/18/13. These laboratory test results were faxed by the laboratory to the facility on 4/18/13, at 2:58 PM. The results showed several critical laboratory values requiring immediate attention. These critical results included a white blood cell count (indicates infection) of 24.9 (normal range 4.0-10.5), hemoglobin (part of red blood cells) of 6.9 (normal range 13.5-18.0, a low value means anemia, a condition in which red blood cells are deficient), and hematocrit (used to measure the number of red blood cells in whole blood) of 22.2 (normal range 42-52, a low value could mean anemia).

During a concurrent interview and record review with the Director of Nurses (DON) on 4/22/13, at 2 PM, the DON stated a Registered Nurse (RN 1) was responsible for reviewing all residents' laboratory results and notifying their physicians of critical results. The DON stated, on 4/18/13, RN 1 gave all residents' laboratory results received on that day to a Licensed Vocational Nurse (LVN 1) to review and notify physicians. The DON further stated LVN 1 did not review the laboratory results; instead, LVN 1 placed the abnormal laboratory results on a clipboard for the physician to review during the physician's routine visit. Resident 1's laboratory results were among the ones on the clipboard. Resident 1's physician (Physician A) did not come in to visit residents that day. On 4/19/13, Resident 1 was found non-responsive and was transferred to an acute hospital at 5:20 AM.

During a review of Resident 1's "ED (emergency department) Physician Notes" on 4/22/13, a complete blood cell count was done as soon as the resident arrived at the emergency department. The results showed his white blood cell count was 49.1 (very critical value indicating systemic infection), hemoglobin was 5.8, and hematocrit was 19.3. Resident 1's diagnosis included anemia, renal insufficiency (loss of kidney functions}, and septic shock (bacteria in the bloodstream that can lead to multiple organ failures including respiratory failure, and may cause rapid death). Resident 1 was unresponsive and had low blood pressure on arrival to the emergency department on 4/19/13, at 6:54 AM. He died in the emergency department within a few hours of arrival.

The DON stated the licensed staff was not even aware of these critical laboratory results until Resident 1's physician came to the facility on 4/19/13, after Resident 1's death, to review the resident's records. Resident 1's physician took the critical laboratory results off the clipboard and showed them to the DON. The facility staff had not reviewed these results until then.

During an interview with Resident 1's physician on 5/16/13, at 9:25AM, he stated he had a meeting on 4/18/13, before the resident's critical laboratory results were received, with the DON and nurses on duty to call him or the physician on call for all laboratory results because there had been problems with the facility not notifying the physicians of laboratory results. The physician stated, "I told them you guys are going to kill somebody." Physician A verified he was the one who reviewed Resident 1's abnormal laboratory results after Resident 1 died in the hospital.

The facility policy and procedure for "Lab (laboratory) and Diagnostic Test Results Clinical Protocol," revised 4/07, was reviewed on 4/22/13. Under the section titled "Review by Nursing Staff," it read, "A nurse will review all results." Under the section "Deciding How Urgently to Contact the Physician," it read, "A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition." Furthermore, under the section of "Identifying Situations that Warrant Immediate Notification," It read: "Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 1. The physician had requested to be notified as soon as a result is received ... " These policies and procedures were not followed by the facility staff.

The facility staff fai led to follow its policy and procedure in notifying physicians of their patients' abnormal laboratory results timely. After the warning from Resident 1's physician, the facility staff did not change their practice. Resident 1's laboratory results were not reported to his physician. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.