Failure to Identify and Respond to UTI Symptoms in Catheterized Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections (UTIs). The resident, an older female with a history of recurrent UTIs, obstructive and reflux uropathy, and chronic bladder spasms, began experiencing increased bladder spasms and dysuria over several days. Despite her increased requests for pain and bladder spasm medications, staff did not identify these as potential symptoms of a UTI or a change in condition, nor did they notify the nurse practitioner or physician for further assessment or order a urinalysis during this period. The resident's medical records showed a pattern of increased administration of pain and antispasmodic medications, and both family members and staff noted that her pain and discomfort were significantly worse than usual in the days leading up to her hospitalization. Family members reported the resident's increased pain and suspected a UTI to nursing staff multiple times, but no action was taken to escalate care or notify the medical provider. Nursing staff interviewed after the incident acknowledged that increased pain and use of PRN medications should have prompted further assessment and notification of the medical provider, especially given the resident's history of UTIs and catheter use. The resident eventually became lethargic and unresponsive, prompting emergency services to be called. Upon hospital admission, she was diagnosed with septic shock due to a UTI, and a suprapubic catheter was surgically placed. Interviews with staff and family confirmed that the signs and symptoms of a UTI and change in condition were present but not recognized or acted upon in a timely manner, resulting in a significant adverse event for the resident.
Removal Plan
- Resident was being treated for pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms and was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment.
- Regional Nurse provided in-service to DNS/Admin/Admin in-training/ADNS regarding process for ensuring changes in conditions are identified and reported to the medical provider, notification of PCP of abnormal labs, implementation of orders as provided, and documentation in the EHR of notification of change in condition to MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.
- Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.).
- Notifying medical provider of the change in condition (increased pain).
- Adhering to physician's orders and recommendations.
- Communicating pertinent information regarding the status of resident's condition to ensure the well-being of residents during the nurse/shift change report.
- Documentation of the resident's status and delivery of care provided according to the plan of care.
- If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA).
- Nurses should conduct on-going monitoring of resident related to the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).
- Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria.
- Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.
- Abuse and Neglect (ANE) - Identifying Prevention and Reporting.
- Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director to review plan of removal/immediate corrective action plan implemented.
- Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents, including those with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place.
- Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place.
- Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift; comprehension verified through follow up questions.
- Director of Nursing/Assistant Director of Nursing will conduct rounds to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
- Director of Nursing/Assistant Director of Nursing will conduct random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any signs and symptoms of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
- Director of Nursing/Assistant Director of Nursing will conduct random interviews with the nursing team members to identify competency/comprehension of identifying signs and symptoms of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented within the electronic health record.
- The facility will conduct a Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is noted within the Electronic Health Record (E.H.R.).
- Director of Nursing/Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) - Nurses will be in serviced prior to working their next shift.
- DNS/Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires.