Failure to Complete Ordered Urinalysis Following Family Request
Penalty
Summary
The facility failed to ensure that a nurse practitioner's order for a urinalysis (UA) was completed for a resident after the resident's responsible party expressed concerns about a possible urinary tract infection (UTI). The resident, an elderly female with diagnoses including dementia, congestive heart failure, chronic kidney disease, history of stroke, and breast cancer, was noted to have moderate cognitive impairment and required substantial assistance with activities of daily living. Her care plan included interventions for bladder incontinence and monitoring for signs and symptoms of UTI, with instructions to report such symptoms to the medical provider. On a specific date, the resident's family requested a UA due to the resident expressing discomfort during urination. The Assistant Director of Nursing (ADON) documented the family's request and notified the Director of Nursing (DON), who in turn sent a message to the medical provider. The medical provider's note confirmed that an order for a UA was approved by the nurse practitioner. However, review of the resident's electronic health record revealed that no order for a UA was entered or completed. Documentation in the facility's 24-hour nurse reports over subsequent days continued to reflect the family's ongoing concerns and requests for a UA, but no action was taken to complete the test. Interviews with facility staff revealed breakdowns in communication and follow-through. The DON acknowledged missing the message regarding the UA order and stated that the ADON should have entered the order and ensured its completion. Nursing staff reported documenting the family's concerns in the 24-hour report, which was supposed to be reviewed during daily meetings, but the DON admitted she did not always review these reports herself. The medical provider confirmed that a delayed UA could place the resident at risk, and the facility's policy emphasized the resident's right to receive services included in their care plan. Despite repeated documentation and family requests, the UA was never completed, constituting a failure to provide care in accordance with professional standards and the resident's care plan.