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F0690
D

Delay in Urine Sample Collection and UTI Treatment

Mentor, Ohio Survey Completed on 12-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to timely collect a urine sample and initiate antibiotic treatment for a resident who exhibited signs of a possible urinary tract infection (UTI). The resident, who had multiple diagnoses including COPD, diabetes, and a recent hip fracture, was noted to have increased confusion, prompting a request from the resident's daughter for a urinalysis with culture and sensitivity (UA C&S). Although the need for a urine sample was communicated between nursing shifts, the sample was not collected promptly, as the resident had just used the restroom when the nurse attempted collection, and the task was passed to the oncoming nurse. Despite documentation of the UA C&S order and ongoing family inquiries about the results, there was a significant delay in both obtaining the urine sample and starting antibiotic therapy. The positive urinalysis was noted several days after the initial request, and the antibiotic order was not placed until eight days after the family first raised concerns. The DON confirmed that both the urine sample collection and the initiation of antibiotic treatment were not completed in a timely manner.

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