Failure to Notify Provider of Positive Urinalysis Results
Penalty
Summary
The facility failed to ensure that a physician was notified of laboratory results for a resident who had a history of urinary tract infections, renal insufficiency, and chronic suprapubic catheter use. The resident was admitted with multiple urological issues and had recently undergone stent placement due to kidney stones. A urinalysis was ordered by the resident's urologist as part of pre-surgical planning for stent removal, and the urine specimen was collected and sent to the lab as ordered. When the urinalysis results were received, they showed significant growth of pathogens, specifically klebsiella variicola and proteus mirabilis. However, the facility did not update either the resident's primary provider or the urologist with these results. The order for the urinalysis was incorrectly placed under the facility's medical director rather than the urologist who had requested it, resulting in a lack of follow-up. Both the nurse practitioner and the urologist confirmed they were not made aware of the results, and the infection preventionist stated that a provider should have been updated with the results regardless of whether they were positive or negative. Four days after the urinalysis results were available, the resident experienced a change in condition, including dizziness, lethargy, and fever, and was subsequently hospitalized for sepsis. The discharge summary from the hospital indicated the resident was treated for septicemia, with possible sources including a catheter-associated urinary tract infection and pneumonia. Interviews with facility staff confirmed that the resident had no symptoms prior to the acute event, and the lack of provider notification regarding the urinalysis results was not explained by facility staff.