F0684

E

Failure to Timely Complete Ordered UA and Lab Work for Two Symptomatic Residents

Flandreau, South Dakota Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely care and complete ordered diagnostic tests for two residents with concerning symptoms. For one resident with alcoholic cirrhosis, ascites, and acute kidney failure, the physician issued an order on 1/12/26 at 2:57 p.m. to collect a urine analysis (UA) sample and bring it to the clinic that day. Nursing documentation later that afternoon recorded the resident’s complaints of painful urination with sharp pain on attempting to void, increased frequency and urgency, a temperature of 101.1°F, pulse of 103, and pain rated 10/10. Despite these symptoms and the explicit same‑day order for a UA, the urine sample was not collected by facility staff on 1/12/26.

On the following day, staff documented that the resident’s temperature had increased to 102°F and that the primary care provider requested the resident be seen at the clinic that day and to postpone scheduled GI testing. A late entry note indicated the provider, during in‑house rounds, recommended the resident be seen in the clinic due to fever and nausea. At the clinic, a bladder scan showed 906 cc of retained urine, a Foley catheter was inserted, a urine sample was obtained, IV antibiotics were administered, and oral antibiotics were ordered for a suspected UTI. The DON later confirmed there was no documentation of what information had been sent to the physician before the UA order on 1/12/26 and acknowledged that the UA should have been collected that day as ordered, and that not doing so may have caused a delay in treatment. LPN/CC F also stated the UA should have been collected on 1/12/26.

The second resident had a diagnosis of intracerebral hemorrhage and a BIMS score indicating moderately intact cognition. Staff faxed the physician reporting dark black stools for two days and strong‑smelling urine. The physician responded with an order for CBC, CMP, and UA to be done that day, noting the resident was on iron, which could cause dark stools versus GI bleed. The order, faxed on 1/9/26, was not acknowledged in the record until 1/13/26. During this period, the physician emailed on 1/9/26 requesting a status update; LPN/CC F replied that the resident’s vital signs were stable, the resident felt fine, and staff had no further information. LPN/CC F later confirmed that the attached document to the physician’s email was the lab order and that the labs, including UA, should have been collected on 1/9/26 when the order was received.

On 1/13/26, a progress note documented that the CNP had ordered CBC, CMP, and UA to be collected that day. LPN/CC F reported collecting the CBC and CMP at 11:31 a.m., but the CMP had to be recollected by the lab the next morning because the initial sample could not be tested. A subsequent note indicated that the day and evening shifts did not obtain a urine sample and that the resident was asleep, so the UA collection was rescheduled. On 1/14/26, the CMP was collected at 8:15 a.m., and LPN/CC F emailed the physician to review the labs; the physician replied that the labs were okay and later stated a UA was not needed unless the resident had symptoms other than odor. There was no CBC report available for review, and documentation showed the CMP was obtained by the clinic. The DON stated she was unsure when the lab order was received but expected labs to be collected the day the order was received if during lab hours. Staff interviews confirmed that physician orders were to be processed immediately and entered into the EMR the same shift they were received, and that resident 5’s labs, including UA, should have been collected on 1/9/26 when the order was received.