Failure to Notify Physician of UTI Lab Results and Initiate Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely physician notification of a resident's urine culture and sensitivity results, resulting in a lack of prompt treatment for a urinary tract infection (UTI). The resident, who had a history of diabetes and stage 3b chronic kidney disease, reported burning during urination, prompting a physician order for urinalysis with culture and sensitivity. The urinalysis, collected the following day, showed signs of infection, and the subsequent urine culture confirmed the presence of Escherichia coli sensitive to several antibiotics. Despite these findings, there was no documented evidence that the physician was notified of the results, no antibiotic was prescribed, and no care plan was initiated for the UTI. Interviews with the resident and staff confirmed that the resident was not informed of the results and had not received any antibiotics. Nursing staff stated that although attempts were made to notify the physician, there was no documentation of these communications, and no orders were obtained. The Director of Nursing acknowledged that the expected protocol—notification of the physician, obtaining orders, and care planning—was not followed, and the facility's policy required immediate notification of significant changes in a resident's condition, which did not occur in this case.