Nea Baptist Clinic - Pediatrics

Summary Statement of Deficiencies D5813 TEST REPORT CFR(s): 493.1291(g) (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: Based on a review of the laboratory panic value policy, a review of the hematology instrument datalog and patient medical records, lack of documentation, and interviews with laboratory staff, it was determined the laboratory failed to document that the healthcare provider was notified of alert values. Survey findings include: A. The laboratory Alert Values policy (Revised 2/2021) states that a White Blood Cell count (WBC) less than 1.5 and greater than 25 should be treated as panic values. The policy further states "All alert values should be communicated to the physician, the physician's nurse, or authorized personnel. Lab personnel calling the ALERT must state the patient's name and the ALERT value. Lab personnel must document the initials of the person receiving the information and the date and time the ALERT information is give." B. One of one alert value results, observed on the instrument datalog, failed to document that the policy was followed. The medical record of Patient #190466741 does not document that the provider was immediately notified of the patient's WBC result of 29.5 on 1/20/26. C. In an interview at 1:15 pm on 5/6/26, testing personnel #3 (as listed on the CMS-209 form) stated "The result wasn't treated as a critical because it wasn't flagged in the system." 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 --

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 --