Failure to Complete Ordered UA with C&S for Resident with Recurrent UTI
Penalty
Summary
The deficiency involves the facility’s failure to complete a urinalysis (UA) with culture and sensitivity (C&S) as ordered for a resident with a history of urinary tract infections. The resident, who had diagnoses including chronic kidney disease, history of UTIs, and diabetes mellitus, reported having burning with urination for a while and indicated that different medications had been tried without resolving the infection. A quarterly MDS assessment documented that the resident was cognitively intact, dependent on staff for bathing and toileting, required maximum assistance with bed mobility, and was always incontinent of bowel and bladder. The care plan, last reviewed in mid-December, indicated the resident required enhanced barrier precautions due to a multi-drug resistant organism UTI. On a late-December date, a nurse’s progress note documented the resident’s complaint of burning with urination, and the NP was notified, resulting in an order for a UA with C&S. The NP’s order, dated the following day, specified that a UA with C&S was to be collected. However, there was no documentation in the medical record that the laboratory test was ever completed. During an interview, the DON confirmed that the ordered UA with C&S had not been completed, demonstrating that the facility did not ensure the ordered laboratory test was obtained and results communicated as required.
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