Failure to Follow Up on Positive Urine Culture Results
Penalty
Summary
The facility failed to ensure appropriate follow-up and communication regarding a urine culture ordered for a resident with a history of urge incontinence and other significant medical diagnoses, including sepsis and acute respiratory failure. The resident was cognitively intact and had been occasionally incontinent of bowel and bladder. A urinalysis with culture and sensitivity was ordered, but the medical record did not indicate the reason for the order, nor did it contain documentation of any genitourinary assessments or concerns after the order was placed. The urine sample was collected, and the final laboratory report showed significant findings, including the presence of Escherichia Coli at a high concentration, as well as other abnormal urinalysis results. Despite these findings, there was no evidence in the medical record that the urine culture results were communicated to the resident, her medical provider, or her primary care physician. Interviews with the DON and an RN confirmed a lack of documentation or recall regarding the reason for the urine culture, as well as a lack of follow-up or notification to the appropriate parties. Facility policy required prompt notification of changes in resident status, including lab results that could indicate a need to alter medical treatment, but this was not followed in this case.