Failure to Complete Ordered Urine Analysis for Resident With History of UTIs
Penalty
Summary
The deficiency involves the facility’s failure to follow through on a physician order for a urine analysis (UA) for a resident with a known history of urinary tract infections (UTIs). The resident had impaired cognition with diagnoses including Alzheimer’s disease, major depressive disorder, and dementia, and was documented as always incontinent of urine and dependent on staff for toileting hygiene. On 4/6/25, after the resident’s daughter reported that the resident was “rambling,” which she recognized as a sign of developing UTI, an LPN entered an order for a UA with reflex to culture. However, there were no UA results in the record corresponding to this order, and no documentation that the ordered test was obtained. Interviews showed that staff were aware of the resident’s incontinence and risk factors for UTI, but key personnel either did not recall the family’s concerns or were not present. The CNA caring for the resident reported that the resident did not communicate needs and was always incontinent, and the Infection Preventionist later confirmed that incontinence and sitting in urine are risk factors for UTI and that the resident had a past history of UTIs. The LPN who wrote the UA order stated that if a change in condition is reported, they assess, notify the physician, and document, and that urine collection orders are passed to the next shift if not completed; however, the LPN did not recall specific family reports about the need for a UA and there was no evidence the UA was ever collected. The NP, who saw the resident routinely on 4/7/25, stated she was not aware of the UA order and indicated she would expect staff to carry out any orders given. Progress notes between 4/6/25 and 4/25/25 did not reference the 4/6/25 UA order. The physician saw the resident on 4/17/25 and reviewed labs from March, again with no mention of the pending UA. On 4/24/25, progress notes documented the family reporting to the DON that the resident was not at baseline; the physician then offered labs and UA with culture and sensitivity, and the family requested transfer to the hospital. The resident was transported to the hospital, where records showed a diagnosis of acute cystitis/UTI, a UA collected on 4/24/25 meeting criteria for urinary infection, and treatment with Rocephin followed by an oral antibiotic prescription. The facility’s McGeer Criteria form for this infection episode was incomplete, and no concern/grievance form from the family was found for that month.
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