Failure to Timely Obtain, Track, and Act on Urine Lab Results for Suspected UTI
Penalty
Summary
Facility staff failed to provide and follow up on ordered laboratory services for a resident with a suspected UTI. The resident, who had dementia with severe cognitive impairment, required moderate assistance with toileting and other ADLs, was dependent for hygiene, and was incontinent of bladder. A physician ordered a urinalysis (UA) and urine culture on 02/14/26 for diagnosis of UTI, but from 02/14/26 to 02/17/26 there was no documentation that staff obtained the UA, contacted the lab, encountered any difficulty obtaining the specimen, or received any results. The UA specimen was not collected until 02/18/26 at 7:41 p.m., four days after the initial order, despite a lab agreement stating that common tests would be reported the same day and most others within 24 hours, with routine lab days Monday through Friday. After the specimen was collected on 02/18/26, progress notes from 02/19/26 to 02/26/26 contained no documentation regarding the status of the UA, any follow-up with the lab, or any findings. The final UA and culture report, dated 02/27/26, showed growth of >100,000/ml Klebsiella aerogenes and >100,000/ml Hafnia alvei, with susceptibility testing indicating resistance to nitrofurantoin. On 02/27/26, staff documented that the UA with culture and sensitivity results were received and that the physician, who was in the facility, ordered nitrofurantoin 100 mg twice daily for seven days, 13 days after the initial UA order, without documentation of any discussion that the identified organisms were resistant to the prescribed antibiotic. Interviews revealed that nurses were not routinely checking the lab website for results, there was no medical records person monitoring labs, the DON acknowledged not calling the lab or receiving results and stated that no staff had checked on them, and the Administrator was unaware of expected lab turnaround times.
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