Antibiotic Initiated Without Laboratory Confirmation of UTI
Penalty
Summary
A resident with Alzheimer's disease and dementia, who had a Foley catheter, was started on an antibiotic for a suspected urinary tract infection (UTI) without proper laboratory confirmation. After the resident pulled out his catheter, he complained of pain during urination, but there was no evidence of strong odor or color change in the urine. The resident's son expressed concern about a possible UTI and discussed the potential for obtaining a urine sample with the nurse, but no urinalysis (UA) or culture and sensitivity (CNS) testing was performed before the antibiotic was prescribed. Documentation showed that the resident's pain subsided and there were no further complaints or signs of distress, yet an order for Macrobid was received for a possible UTI. The DON confirmed that no UA or CNS was completed before, during, or after the initiation of the antibiotic. The facility's antibiotic stewardship policy requires laboratory testing in accordance with current standards of practice, but this was not followed in this instance.