Delayed Collection of Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure the timely completion of a physician-ordered urinalysis (UA) for one resident. The resident, who was mildly cognitively impaired, had a physician's order for a UA with culture and sensitivity if indicated. The order, dated 07/18/2025, did not specify collection instructions. Nursing documentation on the same day noted that staff were awaiting a urine sample from the resident. The UA was not collected until 07/21/2025, three days after the order was placed, and was then sent to the lab. Interviews with facility staff revealed that standard practice was to collect UAs within the same shift or within 24 hours of the order. Staff indicated that a three-day delay in collection was not considered timely. The Director of Nursing identified that the order was entered but not scheduled in the electronic medical record, which prevented the system from alerting nurses to complete the lab. This resulted in the UA not being collected in a timely manner as required.