Failure to Obtain Timely Urology Consult and Urine Culture
Penalty
Summary
The facility failed to obtain a timely urology consult and urine culture for a resident with a history of mild cognitive impairment and partial dependence in activities of daily living. The resident was care planned as being at risk for complications related to their diagnosis and required regular care and laboratory monitoring. Physician orders were in place for a urologist consult and for results to be faxed to the urologist, with follow-up also ordered. However, documentation showed that the consult was dependent on a referral, and there was no evidence of follow-up to ensure the referral was completed. Medical Records staff confirmed that no follow-up occurred for the urologist consult prior to the resident's transfer to the hospital. Additionally, there was a delay in obtaining a urine culture and sensitivity (C&S) for the same resident. Although an order for the culture was present, the specimen was not collected and reported in a timely manner. The Assistant Director of Nursing was unable to explain the delay in obtaining the sample. These failures resulted in the resident not receiving timely assessment and intervention as required by their clinical condition and care plan.
Plan Of Correction
F 690 On , the medical staff made the records/ consult for resident #1. On , resident # 1 was reevaluated by the provider with no acute findings. On , the Regional Nurse Consultant conducted a quality review of current residents with to ensure physician orders for consults and cultures in the past 30 days have been followed timely. No additional findings were noted. By , licensed nurses were educated by the Staff Development Coordinator on F 690 with an emphasis on obtaining consults and cultures timely. As part of a systematic change, newly hired licensed nurses will be educated on F 690 with an emphasis on obtaining , consults and cultures timely. DON/Designee will conduct quality monitoring of order listing reports 5 times weekly x 4 weeks, then 10 order listing reports monthly x 2 months to ensure that cultures and consults are obtained timely. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 690