Failure to Timely Collect Ordered UA C&S After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered urinalysis with culture and sensitivity (UA C&S) was collected in a timely manner after a resident experienced a change in condition with painful urination. The resident had a history of urinary tract infection and, on 11/5/25, the physician ordered a one-time UA C&S for painful urination. An SBAR dated 11/5/25 documented that the resident complained of pain while urinating, was given pain medication with effective relief, had vital signs within normal limits, and that new orders for a UA C&S were obtained. The Director of Nursing stated that the urine should have been collected as soon as possible and was unable to find documentation that the urine was collected on 11/5/25 or 11/6/25, nor any documentation of attempts or inability to collect the specimen during that time. Documentation shows that the urine was not collected until 11/7/25, as reflected in a nurse’s note and an SBAR on that date indicating that the resident’s urine was collected that morning due to painful urination. Later that day, the resident reported increased pain with urination, refused to wait for the UA C&S results, and requested transfer to the hospital, with family and the physician notified. Emergency department records from the acute hospital documented a discharge diagnosis of urinary tract infection. During an interview, the LVN assigned to the resident on the day shift when the order was received stated she could not recall if she attempted to collect the urine on that shift, and acknowledged she was supposed to collect the urine to ensure it was done on time and without delay of care. The facility’s policy on acute condition changes states that staff will monitor and document the resident’s progress and responses to treatment, and that the physician will authorize appropriate treatments.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.