Failure to Enter and Implement Physician Order for Urinalysis
Penalty
No penalty information released
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Summary
A deficiency occurred when a physician ordered a urinalysis (UA) for a resident with a chronic indwelling catheter and a history of urinary tract infections (UTIs) due to the presence of spasms. The order was discussed with nursing staff on the date of service, but the Licensed Vocational Nurse (LVN) assigned to the resident did not enter the physician's order into the system. As a result, the urinalysis was not ordered or collected as required. Review of facility policy confirmed that nurses are responsible for promptly and accurately entering new physician orders into the Medication Administration Record (MAR/eMAR). This failure led to a delay in care for the resident.