This case involves an elderly male patient that was admitted to the hospital for a suspected UTI related to indwelling catheter use. A urine culture was ordered by a nurse practitioner, however the patient was discharged before the results were reviewed. It was later revealed that the test results were sent to the wing of the hospital in which the patient was staying, however they were not brought to his care providers. A few days after being discharged from the hospital the patient presented to the emergency room with signs of a worsening infection. The patient required multiple surgeries in order to repair damage done by the untreated infection, and continues to suffer from ongoing urinary tract dysfunction.