Delayed UTI Treatment and Inadequate Bladder Monitoring Result in Resident Harm
Penalty
Summary
A deficiency occurred when a resident exhibiting signs and symptoms of a urinary tract infection (UTI) was not treated in a timely manner. The resident, who had a history of multiple medical conditions including metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder, and osteoporosis, was identified as being at risk for bladder incontinence and was incontinent of bladder. Despite these risk factors, the care plan was not updated beyond the baseline, and there were no interventions documented for bladder incontinence. On a specific date, the resident began to show symptoms of a UTI, including foul-smelling urine, burning during urination, and abdominal pain. The physician was notified, and orders for a urinalysis (UA) with culture and sensitivity (C&S) were placed. Although the urine sample was collected and the order was changed to STAT for immediate pickup, the laboratory results were not reported back to the facility until several days later. During this period, there was no documentation or monitoring of the resident for bladder issues, and no interventions were implemented to address her incontinence or potential urinary retention. The resident did not receive antibiotic treatment for the UTI until six days after the initial symptoms were observed. She was subsequently transferred to the hospital, where it was discovered that she had significant bladder distention with renal pelvictasis. Interviews with facility leadership confirmed that there was a lack of timely intervention and monitoring for bladder issues, and the medical director indicated that nursing staff should have assessed for bladder distention during the period in question. The facility's own policy outlined the need for prompt assessment, monitoring, and treatment of UTIs, which was not followed in this case.