Failure to Timely Review and Act on Urinary Lab Results Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that physician orders from a urologist were completed and reviewed according to professional standards of practice for a resident with a history of diabetes, obstructive uropathy, and dementia. The resident, who was frequently incontinent and required extensive assistance with activities of daily living, experienced a change in urinary condition, including painful urination and hematuria. Orders were given for a urinalysis (UA) with culture and sensitivity (C & S), but there was no documentation that the UA was completed as ordered prior to a scheduled cystoscopy. After the cystoscopy, another UA was ordered and collected, but the results were not reviewed or acted upon in a timely manner. The medical record showed that the UA with C & S results, which indicated the presence of multi-drug resistant bacteria, were not reviewed by the facility's medical provider until 14 days after collection. During this period, the resident exhibited increased behavioral symptoms, including aggression and lethargy, but the pending laboratory results were not referenced or addressed in interdisciplinary team meetings or provider notes. Communication breakdowns occurred among licensed nurses, the medical provider, and the director of nursing, with staff assuming others had received and addressed the results. The director of nursing was unaware of the pending UA with C & S until contacted by the resident's representative. The delay in reviewing and acting upon the laboratory results contributed to the resident's hospitalization for septic shock due to urosepsis. Interviews with staff and the resident's representative confirmed that the facility did not respond promptly or thoroughly to the resident's change in condition, and the laboratory results were not followed up in accordance with facility policy or professional standards. The failure to ensure timely review and response to critical laboratory findings resulted in harm to the resident.