Failure to Obtain Ordered Urinalysis and Notify Provider
Penalty
Summary
Nursing personnel failed to follow physician orders for a resident who was admitted with multiple diagnoses, including Alzheimer's disease, dementia, hypertension, and chronic pain. The facility received an order to obtain a urinalysis (UA) for the resident after family members expressed concerns about urinary symptoms. While a complete blood count (CBC) was obtained and sent to the lab, staff were unable to collect a urine specimen before the lab closed for the weekend. The resident's power of attorney was notified, and fluids were encouraged, but the UA was not obtained as ordered. The facility did not have a policy addressing the process for following physician orders or steps to take if orders could not be completed. Nursing staff communicated the inability to obtain the UA to the nurse practitioner via email but did not receive a response or further instructions. There was no documented follow-up with the provider or escalation to an on-call provider as expected. Interviews with facility staff and consultants confirmed that the standard practice would be to contact the provider for further direction if an order could not be completed, but this was not done in this case.