Failure to Promptly Notify Practitioner of Abnormal Urine Culture Result
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of an abnormal urine culture result and to follow its own lab notification policy for one resident. The resident was admitted with diagnoses including acute kidney failure, diabetes, and a urinary tract infection, and had a BIMS score of 6/15, indicating severely impaired cognition. A urine culture collected on 11/12/2025 was reported to the facility on 11/14/2025 at 1:49 PM as abnormal. However, progress notes show that antibiotic therapy was not ordered until 11/18/2025, when a nurse practitioner reviewed the urine culture results and initiated treatment. Interviews with the UM/LPN, DON, Regional Nurse, and the nurse practitioner established that facility expectations and policy required nurses to promptly notify the practitioner of abnormal lab results once received. The UM/LPN stated that a four-day delay in notifying the provider of an abnormal lab result would be considered a delay in care and acknowledged that policy was not followed for this resident. The DON and Regional Nurse confirmed that although clinicians can access lab results in the electronic system, nurses are expected to alert them when abnormal results are received, and that lack of notification and documentation means the policy was not followed. The nurse practitioner caring for the resident stated that the provider should have been notified on the date the abnormal result was reported and confirmed that the delay constituted a delay in care.
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