Delayed STAT Urine Specimen Pickup and Lack of Documentation
Penalty
Summary
The facility failed to ensure that a STAT urinalysis (UA) and urine culture and sensitivity (C&S) specimen for one resident was picked up by the laboratory within the required 4-6 hour timeframe. The resident, who was cognitively intact and admitted with osteomyelitis, experienced a change in condition characterized by confusion and hallucinations. The physician ordered a STAT UA with C&S to rule out a urinary tract infection. Documentation showed that the urine sample was collected in the evening, but the laboratory did not pick up the specimen until the following morning, well beyond the facility's policy timeframe for STAT orders. Interviews with the Director of Nursing (DON) and the nurse involved confirmed that the facility's policy requires immediate notification to the lab for STAT orders and documentation of this communication. The DON verified that there was no documentation indicating the lab was called to expedite the STAT order, and the nurse could not recall if she had contacted the lab before her shift ended. The facility's policy, which was reviewed, clearly states that STAT orders must be called in to the laboratory immediately and prioritized for completion within 4-6 hours, which did not occur in this instance.