Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
Staff failed to follow a physician's order for a resident who was admitted with multiple diagnoses, including a fracture of the lower end of the left femur, generalized muscle weakness, pain in the left hip, and repeated falls. The physician had ordered a urinalysis with culture and sensitivity to be collected from the resident's Foley catheter, specifically instructing that the sample be collected from the tube and not the collection bag. Documentation on the treatment administration record indicated that the urine sample was collected as ordered. However, a review of the medical record revealed that there were no laboratory results for the urinalysis or culture and sensitivity. During an interview, the unit manager confirmed that there were no results on file and was unaware that the urinalysis had not been collected. Upon contacting the laboratory, it was confirmed that the urine sample was never received for processing.