Failure to Follow Physician Order for Urine Dipstick Testing
Penalty
Summary
A deficiency occurred when a physician's order for urine dipstick testing was not followed for a resident with a Foley catheter and a history of urinary retention, dementia, and benign prostatic hyperplasia. The resident exhibited symptoms including feeling unwell, appearing pale and dizzy, and experiencing chills while eating in the dining room. The family requested the nurse to check for a urinary tract infection (UTI). The nurse contacted the physician, who ordered immediate blood tests, but did not perform the urine dipstick as previously ordered for signs or symptoms of UTI. The nurse stated the intention to complete the dipstick test after returning from a break, but the family took the resident to the hospital before it was done. Medical record review confirmed there was a standing physician order to perform a urine dipstick if signs or symptoms of UTI were present, and to send urine for culture and sensitivity if the dipstick was positive for leukocytes. There was no documentation that the urine dipstick was performed or that urine was obtained for testing as ordered. Interviews with the nurse and the Director of Nursing confirmed the expectation that the order should have been followed, but no explanation was provided for the failure to complete the test prior to the resident's transfer to the hospital, where the resident was admitted with a UTI diagnosis.