Summary:
Summary Statement of Deficiencies D5813 TEST REPORT CFR(s): 493.1291(g) The laboratory must immediately alert the individual or entity requesting the test and, if applicable, the individual responsible for using the test results when any test result indicates an imminently life-threatening condition, or panic or alert values. This STANDARD is not met as evidenced by: Through a review of the laboratory alert values policy, a review of five patient complete blood count (CBC) reports, and interviews with laboratory staff, it was determined the laboratory failed to immediately alert the provider of test results listed as alert values in the policy and procedure manual. Survey findings include: A. The "NEA Baptist Pediatric Clinic Alert Values" included in the Policy and Procedure Manual list alert values for WBC (White Blood Cell) as less than 1.5 or greater than 18. B. During a review of a complete blood count performed on patient #140665618 on 12/30/2020 it was determined the WBC was reported as 18.6. There was no documentation on the report that the provider had been notified of the alert value WBC. C. In an interview, at 11:00 on 1/21/2021, laboratory employee #4 (as listed on the form CMS-209) stated that alert values will have a flag in the system and will not allow the testing personnel to go any further in the system until the notification of the provider is documented. She further stated that testing personnel notify providers if the result is flagged as an alert value. D. A review of the above listed patient report revealed the WBC result was not flagged to alert the testing personnel that the result was above the alert value cutoff. E. In an interview, at 11:04 on 1/21/2021, laboratory employee #3 (as listed on the CMS-209 form) confirmed the value listed on the patient report was an alert value but was not flagged as one. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --