Failure to Timely Complete and Follow Up on Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis, culture, and sensitivity test for a resident with acute kidney failure was completed in a timely manner. The initial urine specimen collected on October 13, 2025, was not tested by the laboratory due to improper labeling, as indicated by the laboratory report dated October 14, 2025. There was no documentation that the urine test was completed, and no follow-up was conducted to recollect the specimen after the initial error. Additionally, the physician was not notified of the missed test until October 20, 2025, at which point a new order for the urine test was made. As a result, the resident's urine was not tested until October 21, 2025, when the laboratory report revealed a urinary tract infection caused by Klebsiella Pneumoniae ESBL. The delay in testing led to a delay in the resident receiving appropriate antibiotic treatment. The Director of Nursing confirmed that the lack of follow-up and delayed notification to the physician contributed to the delay in addressing the resident's infection.