Failure to Obtain Timely Laboratory Services
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident diagnosed with heart failure and major depressive disorder. The resident experienced a fall on November 1, 2024, and a urine sample was requested due to a history of urinary tract infections (UTIs). An interdisciplinary team reviewed the fall incident on November 4, 2024, and a new order was issued to obtain a urine analysis and culture sensitivity test (UA C&S) to rule out infection as a cause of the fall and increased behavior. Despite the order, the UA C&S was not collected until November 22, 2024, after a physician/nurse practitioner noted on November 21, 2024, that the test was needed due to dysuria. The delay in obtaining the urine sample resulted in a positive UTI diagnosis. During an interview, the Nursing Home Administrator expressed that the UA C&S should have been obtained earlier. This deficiency highlights the facility's failure to provide timely laboratory services as required.
Plan Of Correction
1. This event is unable to be corrected as it is a past event. U/A was obtained. 2. Nursing notes audited for past 14 days to ensure any lab requests had timely follow up from physician and orders entered into PCC for collection. 3. Re-education provided to licensed staff on antibiotic stewardship and s/s of UTI. Education provided to nursing staff to ensure orders requested have been addressed by MD and orders entered as indicated. Education provided to physicians on the importance of providing follow up to nursing request(s). 4. Audit daily Monday-Friday of progress notes for lab requests and if order obtained by MD and entered into PCC for collection x2 weeks; then 3x per week for 2 weeks; then monthly x2 months by DON or designee. Results to QAPI. Date of compliance 01/14/2025.