Delay in Addressing Lab Results Leads to Postponed Procedure
Penalty
Summary
The facility failed to ensure timely follow-up and treatment of a resident's laboratory results, specifically regarding urine cultures ordered to monitor for infection. The first urine culture, obtained as ordered, revealed the presence of ESBL and included instructions to follow contact precautions. Despite the results being available and verified, there was no documented evidence that the physician was notified or that treatment was initiated until over two weeks later, when a nurse documented contacting the physician and receiving new orders. Progress notes indicated that the lack of timely action on the lab results led to uncertainty about whether the infection had been treated. As a result of this delay, a scheduled ureteroscopy with stone removal was canceled because the infection had not been addressed. The resident ultimately received the required procedure nearly a month later, after a second urine culture and appropriate antibiotic treatment were initiated. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation regarding physician notification and treatment initiation.