F0773

D

Failure to Promptly Notify Physician of Abnormal UA Results Leading to Delayed UTI Treatment

Denison, Texas Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify the physician of abnormal laboratory results for a cognitively intact female resident with heart failure, dementia, and COPD. The resident’s quarterly MDS showed she required partial to moderate assistance with ADLs and had bladder and bowel incontinence. On 01/27/26, a verbal order was obtained for a urinalysis with culture and sensitivity if indicated. The urinalysis, completed on 01/29/26, showed positive urine nitrates and white blood cells too numerous to count, findings consistent with a urinary tract infection. Despite these abnormal results, the physician was not promptly notified, and an antibiotic (Macrobid 100 mg twice daily for 10 days) was not started until 02/04/26.

The resident reported that she had burning on urination, believed she had a UTI, and stated that after providing a urine specimen it took 5–6 days before she received any medication. She said she was finally feeling a little better and that the urinary burning had stopped while she was still taking the prescribed medication. Nursing staff interviews revealed gaps and delays in the notification process. One LVN stated that the process for labs was to place them on the 24-hour report for follow-up and that, upon receiving results, staff would text or fax the results to the physician. She reported notifying the physician by text on 02/03/26 and was unsure why the physician had not been notified sooner, noting that this occurred during an ice storm when the physician’s office was closed.

Another LVN working nights stated that when lab results are uploaded, she prints them and places them in the physician’s binder for day-shift staff to call the physician with results, and she believed she had printed the resident’s lab report on 01/29/26. A third LVN, who worked the weekend of 01/31/26, stated she saw the resident’s lab results and observed there was no documentation in the progress notes or 24-hour report indicating the physician had been notified, so she faxed the results to the physician’s office and returned them to the physician review book. The physician stated his expectation was to be contacted by phone for any abnormal lab results, did not recall receiving a call from the facility, and acknowledged that not being notified could result in a delay in treatment. The facility’s lab and diagnostic test results policy required a nurse to review results, determine urgency, notify the physician by phone, fax, or agent, and document when, how, and to whom the information was provided, with direct voice communication preferred for results requiring immediate notification.