Failure to Timely Obtain and Process Ordered Urinalysis
Penalty
Summary
The facility failed to timely obtain and process a urinalysis as ordered by a certified nurse practitioner (CNP) for a resident with a history of urinary tract infection (UTI) and urinary retention. The resident, who was cognitively intact and required assistance with toileting, had an order to remove an indwelling catheter and perform straight catheterization every four to six hours. On a subsequent date, the CNP ordered to hold Cipro, start intravenous Ceftriaxone, and obtain a urinalysis due to ongoing infection concerns. However, the CNP was not informed that the resident was not receiving Cipro as ordered, nor that straight catheterization was not being performed as prescribed, despite evidence of significant urine retention. Interviews and record reviews confirmed that although urine was collected for the urinalysis, it was never sent to the laboratory, and no results were available in the medical record. The DON confirmed the urine sample was not processed and could not provide a reason for this failure. The CNP was not notified that the urinalysis was not completed, and only became aware of the issue during the investigation. This deficiency was identified during the course of a complaint investigation.