Failure to Notify Provider of Resident's Change in Condition Related to Catheter and UTI Symptoms
Penalty
Summary
The facility failed to immediately notify a resident's nurse practitioner (NP) when there was a significant change in the resident's physical status. The resident, who had a history of urinary tract infections (UTIs) and required an indwelling catheter, began experiencing increased bladder spasms and dysuria over several days. Despite these symptoms and an increased need for pain and bladder spasm medications, there was no documentation or evidence that the NP was notified of the change in the resident's condition. Medical record reviews showed that the resident was administered oxybutynin chloride and phenazopyridine HCl multiple times over a period of days for bladder spasms and dysuria, indicating ongoing and possibly worsening symptoms. Interviews with nursing staff confirmed that the resident's increased pain and medication use should have prompted notification to the NP, as these could indicate complications such as catheter obstruction or a UTI. The NP also stated she would have expected to be notified and for a urinalysis to be conducted if the resident was experiencing increased pain. The resident herself reported experiencing excruciating pain for several days prior to being sent to the hospital, requiring frequent requests for pain medication. Facility policy required that the physician and resident representative be notified of changes in condition or symptoms suggestive of a UTI, but this was not followed. The failure to notify the NP of the resident's change in condition was confirmed through interviews, record review, and review of facility policy.