Failure to Obtain Provider-Ordered Urinalysis Resulting in Hospital Transfer
Penalty
Summary
Facility staff failed to obtain a provider-ordered urinalysis for a resident with a history of chronic kidney disease, bladder cancer, diabetes, and recurrent urinary tract infections. The urinalysis was ordered after the resident's husband expressed concerns about changes in her mental status, but the test was not completed. Documentation by an LPN indicated the urinalysis was not obtained during the shift, and although it was noted in shift and 24-hour reports, it was not communicated in the MD/Nursing communications report. No requisition for the urinalysis was found in the lab book, and the laboratory company confirmed that no urinalysis was performed for the resident on the ordered date. Following the missed urinalysis, the resident's condition deteriorated, with staff documenting decreased oral intake, altered mental status, and increased resistiveness to care. The resident's husband repeatedly contacted the facility due to ongoing concerns about her health and ultimately requested that she be sent to the emergency department. Upon transfer, the resident was found to have abnormal urinalysis results, dehydration, and altered mental status, and was treated with IV fluids and antibiotics for a urinary tract infection. The facility's policy required timely provision or procurement of laboratory services when ordered by a provider. Despite this, the ordered urinalysis was not obtained, and there was a lack of effective communication and follow-through among staff to ensure the test was completed. The failure to obtain the urinalysis contributed to the resident's transfer to a higher level of care and subsequent treatment for a UTI and related complications.