Failure to Obtain and Report Ordered Urinalysis
Penalty
Summary
A deficiency occurred when the facility failed to obtain a urinalysis for a resident as ordered by the nurse practitioner. The resident, who had a history of traumatic brain injury, hemiplegia, hypokalemia, chronic pain, chronic kidney disease stage three, stress incontinence, and irritable bowel syndrome, was admitted with ongoing urinary incontinence. On the date of the incident, the resident complained of burning with urination, and the nurse practitioner ordered a urinalysis and urine culture and sensitivity. The resident was aware of and agreed to the order. Despite documentation in the Medication Administration Record indicating that the urinalysis was collected, a review of the medical record, lab results, progress notes, physician notes, and the facility infection control log revealed no results for the urinalysis and no evidence that the ordering provider was notified about the missing results. Interviews with an LPN confirmed that the lab did not receive a urine specimen for the resident and that no provider was contacted regarding the absence of results. Facility policy required timely notification of lab results to providers, which was not followed in this instance.