Failure to Obtain and Document Ordered Urinalysis for Resident with Suspected UTI
Penalty
Summary
The facility failed to ensure that a urinalysis (UA) was collected as ordered for a resident with diagnoses including cellulitis, diabetes, and heart failure, who was cognitively intact. The resident's daughter reported increased confusion and suspected a urinary tract infection (UTI). Multiple physician orders were placed to obtain a UA due to the resident's altered mental status and increased confusion. Documentation shows that the resident was educated on the need for a urine sample and refused a straight catheterization, agreeing only to use a bedpan. Attempts to collect a sample were unsuccessful, including a bedpan spill and further refusals of straight catheterization. There was a lack of documented attempts, refusals, or notifications regarding obtaining the urine sample during several days in the period when the UA was ordered. The Director of Nursing acknowledged that refusals and education provided to the resident were not well documented. The resident was later admitted to the hospital with a primary diagnosis of acute cystitis. The deficiency centers on the facility's failure to ensure timely collection and documentation of the ordered laboratory test and communication with the practitioner.