Failure to Timely Review Lab Results and Administer Appropriate Antibiotic for UTI
Penalty
Summary
A resident was admitted to the facility and had a urine sample collected for urinalysis, which later tested positive for a urinary tract infection (UTI). The urinalysis report, which indicated the presence of bacteria resistant to Cipro, was not signed off as reviewed by staff. Despite the resistance noted in the report, Cipro was ordered and administered to the resident five days after the urinalysis results were available. There was no documentation in the progress notes regarding the UTI diagnosis or the use of Cipro during this period. Subsequently, the resident developed a fever and decreased intake, leading to hospital admission where they were diagnosed with sepsis secondary to the UTI. Upon return to the facility, the resident had a care plan for sepsis with ESBL and E. coli bacteremia and was prescribed intravenous Ertapenem. Interviews with the Unit Manager and DON confirmed the urinalysis was not reviewed in a timely manner and that the antibiotic administered was not appropriate for the identified bacteria.