Failure to Assess and Treat UTI and Foot Wounds
Penalty
Summary
The facility failed to properly assess, identify, and treat wounds on the feet and a urinary tract infection (UTI) for Resident #2, who was one of three residents reviewed for a change in condition. Upon re-admission, Resident #2 had multiple diagnoses, including difficulty walking, diabetes, and a history of UTI. Despite a progress note indicating blood-tinged urine and an order for urinalysis and culture, there were no results documented in the medical record. The resident's condition worsened, with dark orange urine and loose stools, leading to a physician's order for IV hydration and antibiotics. However, the family insisted on hospital transfer due to the resident's declining health. At the hospital, Resident #2 was diagnosed with a complicated UTI, acute kidney injury, and osteomyelitis of the right great toe. The hospital records revealed a foul-smelling discharge from the toe, which was not documented or treated at the facility. The resident's condition included dehydration and renal failure, and the family opted for hospice care after a discussion about potential amputation of the toe. The resident eventually passed away, with the death certificate citing acute osteomyelitis as the main cause of death. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, confirmed the lack of documentation and treatment for the resident's foot wounds and UTI. The facility's policy on preventing catheter-associated UTIs was not effectively implemented, as evidenced by the resident's condition upon hospital transfer. The facility also reported issues with their laboratory services, which may have contributed to the lack of timely diagnosis and treatment.
Plan Of Correction
1. Resident #2 no longer resides in the facility. 2. Like residents are identified as any resident with a change in condition. A sweep was conducted on 3/24/2025 to ensure all residents with catheters and any wound had care plan reviews. Like resident medical records were reviewed between 3/22/25 to 3/25/2024 to ensure appropriate interventions were in place for the prevention of skin breakdown and changes in condition were identified timely and reported to the MD appropriately and timely. All future residents admitted with potential risk factors will be identified upon admission and appropriate interventions implemented in the plan of care timely. 3. The Policy on reporting changes in condition has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate interventions implemented in their plan of care timely. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission with any change in condition between 3/13/25 and 3/21/2025. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.