Failure to Complete Ordered Urinalysis and Accurate Antibiotic Transcription
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis was completed and that an antibiotic was transcribed and administered as ordered for a resident with moderate cognitive impairment following a cerebral infarction. The resident was admitted with orders for a urinalysis, among other tests, but documentation showed that only one attempt was made to collect a urine specimen, which was unsuccessful due to the resident's refusal. There was no evidence of further attempts or documentation that the urinalysis was completed, despite facility policy requiring timely completion of laboratory services as ordered by a physician. Subsequently, the resident experienced a fall and was sent to the emergency room, where they were diagnosed with a urinary tract infection (UTI) and prescribed Keflex 500 mg to be taken four times daily. Upon return to the facility, the antibiotic order was inaccurately transcribed as three times daily, and the resident received the medication at this incorrect frequency. There was no documentation that the facility provider changed the order, and staff confirmed the transcription error. The resident later developed hypoglycemia and sepsis due to UTI, requiring another hospital transfer.