HospitalInspections.org

Based on medical record review and interview the facility failed to ensure physician's orders for urinalysis (UA) testing were followed for 2 of 4 (Patient #1 and 4) sampled patients that received care in the facility's Emergency Department. (ED).

The findings included:

1. Medical record review for Patient #1 showed an ED visit on 1/28/19 with diagnosis of a Right Distal Ureter Calculus.

A physician's order dated 1/28/19 showed "UA with Microscopic and culture if Pos [positive]..."

There was no documentation that the urine specimen was collected, and no documentation of the results of the UA noted.

During an interview on 2/6/2020 at 12:42 PM, the Quality Director verified the UA was not completed as ordered.

2. Medical record review for Patient #4 showed an ED visit on 1/12/19 with diagnosis of Kidney Stone on the Right Side.

A physician's order dated 1/12/19 showed, "Urinalysis w [with] Microscopic if Indicated..."

There was no documentation that the urine specimen was collected, and no documentation of the results of the UA noted.

During an interview on 2/6/2020 at 2:19 PM, the Quality Director verified the UA was not completed as ordered.