Failure to Promptly Notify Physician of Hematuria and Abnormal Urinalysis Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition and subsequent abnormal laboratory results. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and complete bowel and bladder incontinence. On the night in question, a CNA reported to an LVN at 3 a.m. that the resident’s diaper contained blood‑tinged urine. The LVN documented hematuria with no associated pain or burning. At 6:30 a.m., the CNA reported a second episode of blood‑tinged urine. Despite these findings, the physician was not notified until 7:13 a.m., when the oncoming RN contacted the physician after being informed that hematuria had occurred at 3 a.m. and again at 6:30 a.m. Interviews with nursing staff and the DON confirmed that the LVN on duty should have notified the physician immediately upon the first observation of blood‑tinged urine at 3 a.m., in accordance with facility expectations. RN 2, LVN 2, RN 1, and the DON each stated that the physician should have been informed right away of the hematuria, and that there was a delay in physician notification. The facility’s Change in Condition policy, which lists hematuria and laboratory reports as changes requiring prompt handling, specifies that the physician shall be called promptly upon any change in condition, with documentation of all contacts or attempts. A second failure occurred related to the resident’s urinalysis with culture and sensitivity, which had been ordered on the same date as the hematuria. The laboratory results were reported to the facility on 2/17/2026 at 7:37 p.m. RN 1, who worked only until 3 p.m. that day, stated that after her shift the assigned LVNs should have received any faxed lab results and sent an electronic message with the results to the physician that same day. Review of facility phone text messages with the DON showed that a picture of the resident’s urinalysis result was not sent to the physician until the following afternoon, and there was no indication of physician notification on the date the results were received. The DON stated that LVNs should have notified the physician of the urinalysis result when it was received so the physician could proceed with an appropriate plan of care, and acknowledged there was a delay in physician notification.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.