Failure to Obtain Ordered Urinalysis and Notify Physician
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis for Resident #1 and did not document any reason for the omission or notify the physician. Resident #1, who had severe cognitive impairment, required substantial to maximum assistance with activities of daily living, had a history of being on antibiotics, and was known to be prone to UTIs, was admitted on an unspecified date. A comprehensive assessment documented these conditions, and on 01/09/26 a physician order was written for a urinalysis. Record review showed no evidence that the urinalysis was ever collected, and there was no documentation that the physician was informed or that there was any rationale for not obtaining the specimen. The resident’s POA reported that the resident began exhibiting familiar signs of developing a UTI and that she requested the facility obtain a urinalysis, but she did not know if it was ever done. The physician confirmed he ordered the urinalysis at the POA’s request, was aware the resident was susceptible to UTIs, and stated he was not aware the urinalysis had not been obtained and that he should have been notified. Resident #1 was later transferred to the hospital for altered mental status on 02/12/26. In an interview, the DON acknowledged the failure to obtain the ordered urinalysis and the lack of notification to the physician.
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