Failure to Timely Obtain Ordered Urine Sample
Penalty
Summary
The facility failed to follow a physician's order to obtain a urine sample in a timely manner for a resident with a history of paraplegia, depression, ESBL resistance, and urine retention. The resident was on enhanced barrier precautions and required straight catheterization every four hours while awake, with additional catheterization as needed at night. The care plan identified the resident as being at risk for urinary tract infection (UTI) due to their diagnoses and catheterization needs, and noted the presence of a colonized multi-drug resistant organism (ESBL) in the urine. A physician's order for bloodwork and urinalysis (UA) was received after concerns were raised about the resident's behavior and fatigue. Despite the order, the Director of Nursing (DON) completed a laboratory requisition form and provided it to the floor nurse but did not enter a laboratory order into the system, which would have alerted staff to collect the specimen. As a result, staff failed to obtain the urine sample for several days, missing the appropriate collection window. The urine specimen was eventually collected several days after the order was received, and laboratory results showed abnormal findings. The facility's policy required that telephone orders be entered into the resident's chart under the order tab, but this was not done in this instance, leading to the delay.