Failure to Promptly Communicate Abnormal Urine Culture Results to Physician
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify and follow up with the ordering physician regarding abnormal urine culture and sensitivity results for one resident. The resident was an elderly female with cerebrovascular disease, candidiasis, muscle weakness, gait abnormalities, and dementia, with a severely impaired BIMS score and care plan indicating dependence for toileting and a self-care deficit. Her care plan also documented prophylactic antibiotic therapy for recurrent UTIs, but without listed interventions. On 12/24, a progress note documented increased agitation and exit-seeking behaviors, and the physician ordered a urinalysis with culture and sensitivity. The specimen was collected on 12/25 using sterile technique. On 12/27, progress notes showed that urinalysis results were received and sent to the physician, while the culture and sensitivity were still pending. That same day, the resident triggered alarms attempting to exit the facility and was admitted to the secured unit, with the ADON receiving her medications and urinalysis results. On 12/28, documentation indicated increased confusion, continued elopement attempts, and feces on the resident’s hands and bedding. On 12/29 at 1:32 p.m., the urine culture and sensitivity results were reported as abnormal and positive for E. coli. However, the 24-hour report for that date did not show that the lab results were faxed to the physician or that follow-up was required, and the resident’s progress notes for that date did not include the culture and sensitivity results. On 12/30, a progress note documented that the physician was notified of the urine culture and sensitivity results that had been received the previous day, with instructions to follow up with the resident’s urologist and no new orders at that time. The facility documented multiple messages left with the on-call agent and a fax of the lab results to the urologist. Additional notes that day indicated the resident continued on Keflex 250 mg daily as UTI prophylaxis and that a family member requested transfer to the hospital for further evaluation. Interviews with the family member, ADON, Regional Corporate Compliance, and Administrator confirmed that the lab results were not entered on the 24-hour report on the day they were received, that all nurses were responsible for lab follow-up, and that failure to document and communicate labs through the established processes could result in missed follow-up. The facility’s policy stated that when test results are reported, a nurse must review them and, if unable to complete the reporting and documentation process, another nurse should coordinate the procedure, which did not occur as required in this case.
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