Failure to Implement Physician's Orders and Notify Provider Leads to Undiagnosed UTI and Septic Shock
Penalty
Summary
A deficiency occurred when nursing staff failed to implement a physician's order for a urinalysis with culture and sensitivity (UA/CS) for a male resident with multiple complex medical conditions, including hemiplegia, diabetes, and incontinence. The order was entered into the system after blood-tinged urine was observed, but the urine specimen was never collected. Nursing staff marked the order as completed in the Medication Administration Record (MAR) despite not obtaining the sample, and no progress note was made to document the failure or to notify the physician. The oncoming shift was not reliably informed, and the physician was not notified that the diagnostic test was not completed. The facility's process for tracking and following up on laboratory orders was not followed. Unit Managers and Advanced Practice Registered Nurses (APRNs) were expected to check lab logs and ensure completion, but the missing UA/CS was not identified or addressed. The resident's family later requested the test results and discovered the test had not been performed. Interviews with staff confirmed that the standard practice was to notify the physician if a specimen could not be collected, but this did not occur in this case. The resident's care plan included monitoring for signs and symptoms of urinary tract infection (UTI), but there was no care plan for actual urinary infection or blood in the urine. As a result of these failures, the resident's UTI went undiagnosed and untreated, leading to the development of septic shock. The resident became lethargic, developed a fever, and ultimately required emergency transfer to the hospital, where he was found to be in critical condition and required intensive care, including mechanical ventilation and IV antibiotics. The deficiency was determined to have placed the resident and others in Immediate Jeopardy due to the lack of timely diagnostic testing and appropriate medical intervention.