Failure to Obtain Ordered Urinalysis in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for a urinalysis (UA) with culture and sensitivity (C&S) for a resident with a history of recurrent UTIs and complaints of abdominal pain. The resident was admitted with multiple diagnoses including a history of UTI. On 2/5/26, the NP ordered a UA with C&S. On 2/6/26, an LPN documented that the resident refused straight catheterization and that a urine sample could not be obtained. There was no documentation of any further attempts to obtain the ordered UA and C&S at that time, despite the resident’s care plan indicating they were usually continent of urine and able to use the toilet with 1–2 person assist, and a care plan for dehydration related to UTI that included obtaining labs as ordered and reporting abnormal results. Nineteen days later, on 2/24/26, the NP re-ordered the UA and C&S, but there was still no documentation that a urine sample was collected. On 3/1/26, the NP again re-ordered the UA and C&S, and on that same day an RN documented that a UA was collected and sent to the lab using a clean-catch method with a collection hat placed in the toilet. Interviews with nursing staff confirmed that attempts had been made to obtain urine via straight catheterization, that the resident declined this method, and that there were progress notes indicating the resident could urinate in a toilet with assistance. The unit manager could not explain why a clean-catch method was not used earlier, and the Nursing Home Administrator acknowledged that the urine sample was not collected in a timely manner.
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