Failure to Implement Physician Orders and Notify Provider Leads to Resident Neglect and Hospitalization
Penalty
Summary
A deficiency occurred when facility nurses failed to implement a physician's order for urinalysis and urine culture (UA/CS) diagnostic testing for a resident who had exhibited blood-tinged urine. The order was entered into the system and marked as completed, but the test was never performed. The nurse who attempted to collect the specimen was unsuccessful, marked the order as completed in the Medication Administration Record (MAR), and did not document the refusal in a progress note or notify the physician or nursing management. There was no evidence that the failure to obtain the specimen or the resident's refusal was communicated to the oncoming nurse or to the provider, as required by facility policy. Over the following days, the resident's condition deteriorated, with documented fever and pain, but the missing diagnostic test was not identified by nursing staff, the unit manager, or the providers. The resident's family ultimately found the resident cold, clammy, and unresponsive, prompting emergency intervention and hospitalization. The resident was diagnosed with septic shock from a urinary tract infection (UTI) and required intensive care, including mechanical ventilation and life-sustaining measures. The facility only became aware that the UA/CS had not been performed when the resident's wife called to request the results after the resident was hospitalized. The facility did not conduct a thorough investigation into the possible neglect until prompted by the family's inquiry and the survey process. The incident was not reported to the State Agency as possible neglect until it was brought to the facility's attention during the survey. Interviews with facility staff, including the DON, NHA, and Risk Manager, confirmed that the failure to provide the ordered diagnostic testing and to notify the physician constituted neglect, as defined by the facility's own policies.