Failure to Obtain Ordered Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered for a resident who had multiple complex medical conditions, including a history of urinary tract infection, cognitive impairment, and pressure ulcers. Despite physician orders for a urinalysis with culture and sensitivity (C&S) on two separate occasions, there was no evidence in the clinical record that a urine specimen was collected or that lab results were obtained for either order. Nursing staff documented difficulty in collecting a urine sample due to the resident's incontinence and fluctuating ability to cooperate, but did not escalate the issue or document all attempts as required. Interviews with nursing staff and facility leadership revealed that the order for urinalysis was passed between shifts without successful collection, and alternative methods such as straight catheterization were not pursued. The DON and ADON acknowledged that the nurses should have contacted the physician for further instructions or to obtain an order for straight catheterization, but this was not done. The nurses also failed to consistently document their attempts to collect the specimen or to communicate the ongoing issue during daily clinical meetings as expected by facility policy. The resident was ultimately transferred to the hospital by family due to concerns of increased confusion, and hospital records indicated that no urinary infection was found. The facility's policy required timely provision or procurement of laboratory services when ordered, but this was not met in the resident's case, as the ordered urinalysis was not completed and the process for addressing collection difficulties was not followed.