Delay in Initiation of Antibiotic Therapy for UTI Due to Medication Unavailability
Penalty
Summary
A resident with a urostomy experienced increased weakness, lethargy, and confusion following a fall. Nursing notes documented that the resident's urine was dark amber and cloudy, prompting notification of the nurse practitioner and orders for urinalysis and culture. Laboratory results showed significant abnormalities, including elevated leukocyte esterase, increased white blood cells, and high bacterial counts, indicating a urinary tract infection (UTI). Despite these findings, there was a delay in initiating antibiotic therapy. The nurse practitioner ordered Augmentin, but the specific dose was not available in the facility's backup medication system, and the medication was not started until two days after the order was written. Facility records and interviews revealed that staff did not notify the provider of the delay in starting the antibiotic, as required by facility policy. The backup medication system did not stock the ordered dose, and although the pharmacy was contacted, there was no documentation of provider notification regarding the unavailability of the medication. The facility's pharmacy guide instructs staff to notify the provider if a medication is not available, but this step was not documented or carried out, resulting in a delay in treatment for the resident's UTI.