Delay in Treatment and Documentation for Resident with UTI Symptoms
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, heart failure, diabetes, and blindness reported symptoms of a urinary tract infection (UTI) but did not receive timely assessment, documentation, or treatment according to professional standards and the facility's own policies. The resident, who was cognitively intact and able to communicate her needs, informed an LVN during the evening shift that she believed she had a UTI. The LVN reported the complaint to the physician, who instructed the nurse to monitor the resident and obtain a urine analysis, but did not provide any new orders at that time. The LVN failed to document the resident's complaint, assessment, or the physician's instructions in the progress notes or on the 24-hour report, resulting in a lack of communication to subsequent shifts. Over the next several shifts, the resident's pain and symptoms increased, but no further assessment or intervention was initiated until surveyors became involved. The resident repeatedly reported feeling ill and experiencing pain, but staff did not follow up or reassess her condition. The medication administration record did not reflect any pain or new interventions, and the care plan, which included monitoring and administering antibiotics as ordered, was not implemented. The lack of documentation and communication between staff members led to a delay in the resident receiving appropriate treatment for her UTI. Interviews with facility staff, including the ADON, LVNs, physician, and DON, confirmed that the resident's complaint was not properly documented or communicated, and that the expected process for responding to a change in condition was not followed. The facility's policy required prompt assessment, documentation, and communication of changes in condition, as well as implementation of interventions and monitoring. The failure to adhere to these procedures resulted in the resident experiencing increased pain and delayed treatment for her UTI.