Delayed Urine Sample Collection and Physician Notification for Suspected UTI
Penalty
Summary
The facility failed to complete a physician's order to obtain a urine sample in a timely manner for a resident with diagnoses including Alzheimer's disease, dementia, and a disorder of the kidney and ureter. The resident, who had severe cognitive impairment and was frequently incontinent of bladder and bowel, had a physician's order for a urinalysis and culture due to suspected urinary tract infection (UTI). Documentation showed that after the initial order was placed, there were only two documented attempts to obtain the urine sample over a five-day period, with one refusal by the resident and one unsuccessful attempt to collect the sample. No further documented attempts were made until a new order for in-and-out catheterization was received and completed. The resident's clinical record indicated that staff did not consistently document attempts to obtain the urine sample as required, nor did they promptly notify the physician when the sample could not be obtained. The Assistant Director of Nursing confirmed that staff should document each attempt and notify the physician if unsuccessful, but this was not done. The Medication Administration Record and Treatment Administration Record also lacked documentation of ongoing attempts between the initial order and the eventual catheterization. As a result, the urine sample was not obtained until five days after the initial order, delaying the diagnosis and treatment of the resident's UTI.