F0690

G

Failure to Follow Provider Order for Urine Testing Related to UTI Symptoms

Energy, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections for one resident with mixed incontinence and vascular dementia. The resident’s MDS documented moderate cognitive impairment and urinary continence with occasional incontinence, and the care plan included an intervention to observe for signs and symptoms of UTI and notify the physician as indicated. On 11/27/2025, an RN documented that a NP, via secure messaging, ordered a straight catheter urine specimen for urinalysis and culture in response to a prior shift nurse’s report that the resident was confused, hallucinating, and incontinent. There was no documentation of urinalysis or culture results from that date, nor any follow-up documentation to the NP regarding the ordered urine specimen.

The RN later stated she remembered making the note about the straight catheter order but did not recall obtaining the urine sample and indicated she would have reported it to the day shift nurse. The NP confirmed she had documentation of the order for a straight catheter urine sample due to confusion, hallucinations, and incontinence, and that there were no urinalysis results from that date. Leadership, including the DON, Assistant DON, and Administrator, stated their expectation that nursing staff follow physician orders and notify the NP if the urine sample could not be obtained, consistent with the facility’s policy requiring physician orders to be obtained and followed, and that the physician and DON be promptly notified if orders are not followed for any reason. Subsequently, the resident was found by an RN passed out in a dinner plate with bradycardia and was sent to the emergency department, where hospital records documented admission for disorientation and acute cystitis without hematuria.