Delay in Laboratory Testing and Notification for UTI
Summary
A deficiency occurred when the facility failed to ensure that a laboratory test was obtained and processed in a timely manner for one resident. The resident, who had diagnoses including acute cerebrovascular insufficiency, anxiety, depression, and alcohol use, was cognitively intact and required supervision for toileting. An order for a urinalysis (UA) and culture and sensitivity (C&S) was placed, and the urine specimen was initially collected as ordered. However, there was no documentation regarding what happened to the first specimen collected, and the laboratory did not receive it. As a result, a second urine sample had to be collected two days later, and the laboratory did not receive this specimen until the following day. The delay in obtaining and processing the laboratory test led to a delay in identifying a urinary tract infection (UTI) and initiating antibiotic treatment. Nursing notes indicated that the results were pending for several days, and the nurse practitioner was not updated with the results until the laboratory reported them. Interviews with facility staff and the laboratory confirmed that the initial specimen was not received, and there was no clear documentation explaining the delay or the need for a second collection.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with an infected diabetic foot ulcer had abnormal wound culture results indicating multiple pathogens, but staff did not promptly notify the NP as required. The results were available in the electronic system and should have been identified during routine chart checks, but the oversight was not recognized for several days, delaying practitioner notification and subsequent medical intervention.
A resident with chronic renal failure and other urological conditions experienced a significant delay in UTI treatment because abnormal urinalysis and culture results were not promptly communicated to the ordering provider. Despite repeated lab findings indicating infection, nursing staff did not notify the NP, and the NP was unaware of the results due to issues with lab integration and lack of staff communication. Facility policy requiring prompt notification of abnormal results was not followed, leading to delayed care.
Facility staff obtained INR laboratory tests for a resident more frequently than ordered by the physician, performing the test multiple times per week instead of only on Mondays as prescribed. The resident, who was cognitively intact and on anticoagulant therapy, confirmed frequent blood draws, and the DON acknowledged the error.
Facility staff conducted a urinalysis for a resident without first obtaining a physician's order, despite the resident being cognitively intact and having multiple medical diagnoses. Review of clinical records and facility policy confirmed that the required practitioner order was missing prior to the laboratory test.
A resident with severe cognitive impairment experienced delays in obtaining and processing urinalysis tests, leading to a late diagnosis of a UTI on the day of discharge. The facility failed to notify the physician of the delays, contrary to their policy, resulting in a deficiency finding during a survey.
Failure to Promptly Notify Practitioner of Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the ordering practitioner of abnormal laboratory results for a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with daily activities, had a wound specimen collected due to increased edema and purulent drainage. The laboratory results, which identified the presence of Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis in the wound, were sent to the facility but were not communicated to the nurse practitioner until several days later. The delay in notification occurred despite the facility's process for lab result review, which includes making results viewable on the Point-Click-Care system dashboard and requiring the overnight shift to conduct a 24-hour chart check to identify any oversights. The oversight was not recognized until several days after the results were received, at which point the practitioner was notified and appropriate medical interventions were ordered. The facility's policy requires prompt reporting of positive culture results to the practitioner, but this was not followed in this instance.
Failure to Promptly Notify Provider of Abnormal Lab Results Delays UTI Treatment
Penalty
Summary
Facility staff failed to promptly notify the ordering provider of laboratory results that were outside clinical reference ranges for one resident, resulting in a delay in treatment for a urinary tract infection (UTI). The resident had significant medical conditions, including chronic renal failure stage IV, benign prostatic hypertension, and obstructive and reflux uropathy, and was assessed as having moderate cognitive impairment. Orders for urinalysis with culture and sensitivity were placed, and results indicating a UTI were available in the clinical record, but the provider was not promptly informed. Despite multiple urinalysis and culture results showing evidence of infection, there was no documentation that the provider was notified of these abnormal findings. The nurse practitioner (NP) continued to order repeat tests and was unaware of the previous positive results, as the laboratory results were not integrated into the chart in a timely manner. Nursing staff did not communicate the abnormal results to the NP, and the NP reported being unable to obtain information about the labs from staff during visits. Facility policy required nursing staff to identify and promptly communicate abnormal laboratory results to the attending physician, especially when results were problematic or the resident's clinical status was unclear. However, the policy was not followed, and the abnormal results were not conveyed to the provider, resulting in a significant delay in the initiation of appropriate treatment for the resident's UTI.
Laboratory Tests Performed Without Proper Physician Order
Penalty
Summary
Facility staff obtained laboratory tests for a resident without a proper physician's order. Specifically, the resident had a physician's order for an international normalized ratio (INR) test to be performed every Monday. However, clinical record review and laboratory reports showed that the INR was obtained on multiple days throughout the week, not just on Mondays as ordered. The electronic medication administration record indicated that the INR was documented as being obtained daily, except for one day, which was inconsistent with the physician's order. The resident involved had diagnoses including cerebral infarction, type 2 diabetes mellitus, and a prosthetic heart valve, and was on anticoagulant therapy. The resident was cognitively intact and confirmed during an interview that blood was drawn for INR testing about three times a week. The DON acknowledged that the INR should only have been obtained on Mondays, as per the physician's order. Facility policy requires laboratory services to be provided only when ordered by an appropriate practitioner.
Laboratory Test Performed Without Physician Order
Penalty
Summary
Facility staff failed to obtain a physician's order prior to performing a urinalysis for one resident. The resident had diagnoses including schizoaffective disorder and type 2 diabetes mellitus and was assessed as cognitively intact. A laboratory report in the resident's clinical record showed that a urinalysis with microscopic examination was conducted, but review of the physician's orders revealed no documentation of an order for this test. The facility's policy requires laboratory services to be provided or obtained only when ordered by a qualified practitioner. This issue was confirmed through staff interview and review of facility documentation.
Failure to Timely Obtain and Communicate Lab Results
Penalty
Summary
The facility staff failed to obtain laboratory specimens as ordered and did not notify the physician of the delay in obtaining the specimens for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including diabetes and dementia, was admitted to the facility and later discharged home. A urinalysis was ordered on multiple occasions, but there were delays and issues with specimen collection and processing. Specifically, a urinalysis with micro reflex urine culture ordered on May 22 was rejected, and another ordered on May 31 was not collected until June 1. The facility's policy requires that laboratory tests be monitored, tracked, and communicated to the physician in a timely manner. However, the delay in obtaining and processing the urinalysis resulted in a late diagnosis of a urinary tract infection (UTI) on the day of the resident's discharge. The resident was discharged with oral antibiotics for the UTI, and the facility staff did not document the delay or notify the physician as required by their policy. This deficiency was identified during a survey, and the facility's administration was informed of the findings.
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