Delay in UTI Treatment and Failure to Escalate Care
Penalty
Summary
A resident with a history of partial paralysis following a stroke, ESBL, recurrent urinary tract infections, morbid obesity, and congestive heart failure was not provided timely treatment for a urinary tract infection (UTI). The resident's urine culture and sensitivity results, indicating a UTI, were received and the physician, nurse practitioner, and DON were notified. Despite the resident exhibiting symptoms such as urinary frequency, burning, severe pain, and dark, concentrated urine, no new antibiotics were initiated, and there was a delay in escalating care. The infectious disease doctor declined to prescribe antibiotics due to not having seen the resident recently, and the nurse practitioner communicated that if the resident could not be treated in-house, she should be sent out for treatment. Over the course of nearly 48 hours after the positive UTI test results, the resident continued to experience symptoms without appropriate intervention. The resident eventually requested to be evaluated in the emergency room and was subsequently admitted with a UTI. Facility documentation and staff interviews confirmed that prompt treatment was not provided, and the resident was not sent out for evaluation in a timely manner despite clear indications and provider recommendations.