Failure to Timely Obtain Ordered UA and Document UTI Management
Penalty
Summary
The deficiency involves the facility’s failure to timely obtain an ordered urinalysis (UA) with culture and sensitivity and to appropriately document and address a suspected urinary tract infection (UTI) for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, Type II diabetes mellitus, progressive multiple sclerosis, malnutrition, dysphagia, legal blindness, and dementia, and had intact cognition per a recent MDS assessment. On 11/10/25, the physician documented the resident’s complaint of lower abdominal pain and ordered a UA with culture and sensitivity, along with encouragement of fluids while results were pending. A physician order for the UA with culture and sensitivity was entered on 11/11/25, but a progress note on 11/12/25 documented that the UA was not collected. On 11/18/25, another physician order was entered for a UA with culture and sensitivity, along with an order for Ciprofloxacin 250 mg by mouth every 12 hours for three days for infection, without documentation explaining the resident’s ongoing symptoms or the rationale for starting the antibiotic at that time. A progress note on 11/19/25 again documented that the UA was not collected. On 11/20/25, documentation showed the resident appeared in the lab system for a UA, but she had already been on antibiotics for two days; the physician was then asked if the UA was still needed, and on 11/21/25 the physician reported the order could be discontinued. Review of the medical record from 11/10/25 to 11/20/25 revealed no further documentation related to the UTI, and the DON confirmed the UA was not completed timely as ordered, that there was no documentation on 11/18/25 to indicate why the antibiotic was ordered or what symptoms persisted, and that the antibiotic was ordered without a UA. The facility’s Antibiotic Stewardship policy required that culture and sensitivity results and the current clinical situation be communicated to the prescriber to determine if antibiotic therapy should be continued or modified, but the UA was never obtained.
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