Failure to Obtain Physician-Ordered Urinalysis with Culture
Penalty
Summary
Facility staff failed to obtain a physician-ordered urinalysis with culture for a resident who reported burning with urination and discolored urine. The resident, who was cognitively intact and had multiple diagnoses including cerebral infarction, diabetes, hypertension, heart failure, and a history of prostate cancer, had a physician's order entered for a urinalysis with culture and sensitivity after reporting symptoms. Nursing documentation indicated that a urine sample was to be sent to the lab several days after the order was placed. Upon review, there were no results of the urinalysis with culture in the resident's clinical record. The regional nurse consultant confirmed that the lab had no record of receiving or processing the urine sample for this resident, despite a note indicating the sample was sent. The reason for the sample not being provided to the lab could not be determined, and no further information was available prior to the end of the survey.