Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
A deficiency occurred when the facility failed to ensure that ordered laboratory tests were completed in a timely manner for a resident with a urostomy tube who was admitted with a history of recurrent urinary tract infections (UTIs) and blood in the urine. On 7/28/25, a physician ordered a urinalysis with culture and sensitivity (UA/C&S) after reddish urine was observed in the resident's urostomy bag. Although the order was placed and documented in the facility's lab tracking form for collection on 7/29/25, the urine sample was not collected until 7/30/25. The clinical record lacked documentation explaining the delay in collection. During interviews, nursing staff confirmed that the labs were not obtained in a timely manner, and the process for lab orders was described as placing the order in a lab book, typically to be completed during the overnight shift.