F0690

D

Delayed UA Collection and Provider Notification for Suspected UTI

Twinsburg, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely obtain and process a physician-ordered urinalysis with culture and sensitivity (UA C&S) and to promptly notify the provider of positive results for a resident with chronic kidney disease, end stage renal disease, and moderate cognitive impairment. The resident was admitted with occasional bladder incontinence and was noted by a CNP on 12/23/25 to have acute lethargy, altered mental status, and delayed responses, representing a significant change from baseline. In response, the CNP ordered a UA C&S to evaluate for a urinary source of acute delirium/encephalopathy and directed staff to notify the provider when results were available.

Despite this order, the urine specimen was not obtained for 22 days. Multiple Medication Administration Notes documented unsuccessful or incomplete attempts to obtain the urine, including that no urine was obtained and the resident was hydrating, the resident’s refusal to be straight cathed by a male, the resident’s incontinence, and that the lab would not pick up until Monday. There was also documentation that urine was collected into a brief and that the UA was “completed,” as well as later notes stating “unable to collect.” Throughout these entries, there was no documented evidence that the physician or CNP was notified of the ongoing inability to obtain the ordered specimen or of the delays. A subsequent order was written to obtain urine via straight catheter, and the UA C&S specimen was finally collected on 01/14/26.

Laboratory results showed abnormal UA findings, including positive nitrites, and the urine culture grew greater than 100,000 E. coli with sensitivities reported. The lab reported these results to the facility on 01/23/26, but there was no documented notification to the CNP until 01/28/26, after the resident’s daughter requested a copy of the UA results due to her mother’s increased confusion. Interviews with an LPN and the DON revealed that lab results were sent to three different fax machines, that results were often missed if nurses were not aware a resident was awaiting labs, that there were intermittent issues with fax/printer service, and that there was no facility policy regarding labs. The DON confirmed the 22‑day delay in obtaining the UA, the five‑day delay in notifying the CNP of the positive UA C&S, and that nurses did not follow through with monitoring for and acting on the ordered lab and its results.