Failure to Follow Lab Test Orders for Resident with UTI and Behavioral Issues
Penalty
Summary
The facility failed to ensure that physician orders and recommendations for laboratory tests were followed for a resident who was admitted with acute encephalopathy and a urinary tract infection. The resident, who had a history of UTI with delirium, exhibited various behaviors such as increased anxiety, hallucinations, and aggression. Despite the psychiatric nurse practitioner's repeated recommendations to obtain a urine analysis and other lab tests to rule out infectious or metabolic causes of the resident's altered mental status, these tests were not conducted. The resident's clinical records showed ongoing behavioral issues, including aggression towards staff and other residents, refusal of meals and medications, and attempts to leave the facility. The psychiatric nurse practitioner made multiple visits and consistently recommended lab tests to assess the resident's condition, but these recommendations were not addressed by the facility. The resident's condition did not improve, and he was eventually transferred to the hospital, where he was diagnosed with an acute kidney injury and treated for a urinary tract infection. Interviews with the Unit Manager confirmed that the urine analysis ordered by the physician and recommended by the nurse practitioner on several occasions was not completed. This oversight in following medical orders and recommendations contributed to the resident's continued behavioral issues and eventual hospitalization.
Plan Of Correction
The Facility does and shall ensure that routine and emergency Lab services were provided for all residents to meet their health needs. All residents will be reviewed for Lab orders to meet health needs. Education has been done. All nursing staff have/will be educated regarding timely lab services for all residents. Monitoring and random check will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and on-going monitoring will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON