Failure to Ensure Timely and Valid Urine Laboratory Testing
Penalty
Summary
The facility failed to ensure timely and valid laboratory services for urinalysis (UA) and urine culture and sensitivity testing for a resident with significant urinary and renal conditions. The resident had diagnoses including stage 3 chronic kidney disease, a history of UTIs, and a left nephrostomy catheter, with a care plan directing monitoring for UTI signs and symptoms. A nurse’s note documented that a urine sample was collected for testing, and lab records showed a UA with culture and sensitivity was collected on 12/10/25. However, the results were not reported until 11 days later and were marked invalid. A subsequent nurse practitioner note documented the nephrostomy tube status and included an order for another UA with culture and sensitivity. A nurse’s note later indicated another urine sample was collected on 12/26/25, and lab records showed the UA with culture and sensitivity was reported five days after collection, with the specimen rejected due to urine stability lapsing, rendering the results invalid. A physician’s order dated 1/9/26 directed that another UA be completed, but no results for this test were found in the resident’s record. During interview, the Corporate RN Consultant stated that the delay in results from the 12/10/25 UA had only come to their attention on 1/13/26, acknowledged that the 12/26/25 UA had not been completed, and confirmed there was no facility policy addressing timeliness of lab results. The lab company reported having no results yet for the UA ordered on 1/9/26.
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