Failure to Follow Physician Orders and Document UTI Testing
Penalty
Summary
Staff failed to provide appropriate treatment and services for a resident with multiple diagnoses, including dementia, chronic kidney disease, diabetes, and schizophrenia, who was moderately cognitively impaired. The resident complained of burning during urination, and a nurse practitioner ordered a urine culture and urinalysis. However, the initial urine sample was rejected by the lab due to a mismatch in the date of birth, requiring recollection and reorder of the test. Despite this, the facility was unable to provide the results of the recollected urine sample, and there was no documentation of follow-up or results in the medical record. Observations in the resident's room on multiple occasions revealed a strong ammonia odor, which was confirmed by the DON and attributed possibly to a bowel movement, but no immediate action was documented. Interviews with facility staff, including the DON and Unit Manager, confirmed that staff did not follow physician orders for the urine culture and urinalysis, and that the results were not documented or followed up as required. The NP later discontinued the order for the urine tests, but the lack of timely and appropriate follow-up on the physician's orders constituted a deficiency in care.