Delayed UTI Treatment and Improper Catheter Care Identified
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for a resident with a history of severe cognitive impairment and an indwelling catheter. Laboratory results indicating the presence of two types of bacteria in the urine were received by the facility, but there was no documentation that the physician was notified or that antibiotics were ordered until several days later. Interviews with staff revealed that the process for notifying the physician and obtaining antibiotics was not followed as expected, resulting in a delay of four days before treatment was initiated. The delay was attributed to a lack of immediate action to obtain the medication from the emergency drug kit or through a back-up pharmacy service, despite facility policy requiring timely access to medications. Additionally, the facility failed to ensure proper catheter care for another resident with an indwelling Foley catheter. Multiple observations over several days showed the resident's catheter drainage bag and tubing in direct contact with the floor while the resident was in a recliner. This was confirmed by the Director of Nursing, who acknowledged that the drainage bag and tubing should not be on the floor, in accordance with the facility's infection control policy. The deficiencies were identified through record review, staff interviews, and direct observation. The issues included both a lack of timely medical intervention for a UTI and repeated failures to maintain catheter equipment in a sanitary manner, as required by facility policy and standard infection control practices.