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Based on medical record (MR) review and interview, the facility failed to ensure that a positive urinalysis was followed up with a urine culture and that the patient (Patient #1) was notified of a potential urinary tract infection (UTI).

Findings include:

-- Per review of Patient #1's MR, on 1/1/2025, they presented to the obstetrics (OB) unit at Hospital #1 in active labor. A urinalysis was performed at admission, which was found to be positive for a large amount of white blood cells (WBC's). After normal vaginal delivery Patient #1 was discharged home on 1/3/2025.

On 1/4/2025, Patient #1 presented to Hospital #2 with tachycardia (elevated heart rate), fever, and abdominal pain/pressure. Workup revealed possible sepsis, a UTI, possible pyelonephritis (infection of the kidney), and concern for retained product in uterus. Patient #1 was started on antibiotics.

On 1/5/2025, Patient #1 was transferred back to Hospital #1 for further obstetrical and gynecological (OB/GYN) evaluation. Workup at Hospital #1 upon readmission, revealed a UTI. Patient #1 was continued on antibiotics and symptoms improved. On 1/7/2025, Patient #1 was discharged home.

-- Per interview of Staff A, Clinical Staff on 9/24/2025 at 9:35 am, they indicated they believe the process is that if a urinalysis showed presence of bacteria, a urine culture would then be ordered. If a urine culture is found positive, the provider is responsible to follow up and provide the results to the patient.

-- Per interview of Staff B, Staff C, and Staff D, Clinical Staff on 9/24/2025 at 1:45 pm, they indicated that a urinalysis reflex to microscopic test means that if the initial urinalysis detects cells or bacteria, it triggers a microscopic examination. It is then the providers responsibility to determine if a culture should then be ordered. This test does not automatically trigger a culture.

-- Per interview of Staff E, Clinical Staff on 9/24/2025 at 12:30 pm, a urine culture was not ordered following a large amount of WBC's being found microscopically in Patient #1's urinalysis. A urine culture should have been ordered.

Based on document review and interview, in one adverse event reviewed, the facility's Quality Assurance Performance Improvement (QAPI) Program lacked adequate follow through of corrective actions identified during its investigation. This could lead to other similar adverse events.

Findings include:

-- Per review of adverse events documented in the hospital's QAPI Program, in one event, a patient had an untoward outcome. The facility identified corrective improvement actions. Review of documentation did not reveal that corrective actions were completed.

-- During interview of Staff F, Non-Clinical staff on 9/25/2025 at 11:15 am, they acknowledged the above finding.