F0658

D

Failure to Complete Physician-Ordered Urology Referral for Resident With Hematuria

Tulare, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The facility failed to ensure services met professional standards of quality when staff did not carry out a physician’s order for a urology referral for Resident 1. A physician’s order dated 5/12/25 directed that Resident 1 be referred to urology for evaluation of hematuria (blood in the urine). During interview and concurrent record review on 3/12/26, the DON confirmed that Resident 1 had this order but there was no documented evidence that the urology referral had been made, and acknowledged the referral should have been completed. In a separate interview, the Infection Control Preventionist stated that Resident 1 had recurrent UTIs and that the physician had ordered a urology consult on 5/12/25, but upon reviewing the clinical record was also unable to find documentation that the referral was initiated, stating the order might have been missed. Review of the facility’s policy “Provision of Physician Ordered Services” indicated that qualified nursing personnel are required to submit timely requests for physician-ordered services, including consultations, to the appropriate entity, which was not followed in this case.

This failure resulted in Resident 1 not being seen by a urologist and created the potential for untreated urinary tract disease, as noted in the report.