Failure to Obtain Ordered Urinalysis and Culture Due to Process Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to obtain an ordered urinalysis and culture and sensitivity for a resident who was experiencing symptoms of a urinary tract infection, including burning, urgency, and decreased urinary output. The resident, who had a history of chronic kidney disease and moderately impaired cognition, was admitted with frequent incontinence. On the day symptoms were noted, a physician ordered a urinalysis and culture and sensitivity, and an antibiotic was started. The nurse collected the urine sample and entered the order into the electronic medical record and the lab services website, but did not record it in the lab book, which is used by the lab service to identify samples for pickup. As a result, the urine sample remained in the facility refrigerator and was not picked up by the lab, and no test results were available for the period reviewed. The breakdown in the process was confirmed by staff interviews, which revealed that the required step of recording the order in the lab book was missed. The Director of Nursing and other staff acknowledged that the established process for obtaining laboratory tests was not followed in this instance.