Failure to Monitor and Report UTI Symptoms Resulting in Delayed Diagnosis
Penalty
Summary
Nursing staff failed to provide care consistent with professional standards and the resident's individualized care plan for a resident with a history of urinary tract infections and urinary incontinence. Over approximately one month, the resident experienced symptoms consistent with a urinary tract infection, including bladder pain and blood-tinged urine. Despite these symptoms being documented in the medical record, nursing staff did not ensure that the resident's provider was notified, a urinalysis was obtained, or that the hematuria was monitored as required by the care plan and facility policy. The resident's care plan specifically directed staff to monitor and document signs and symptoms of UTI, such as pain and blood-tinged urine, to minimize the risk of septicemia. On one occasion, nursing staff documented blood-tinged urine and blood in the vaginal area, and the nurse practitioner on call ordered continued monitoring and a gynecology consult. However, there was no evidence that a urinalysis was performed or that the hematuria was further monitored. The nurse practitioner later stated he was not informed of the hematuria or bladder pain, and would have ordered a urinalysis if he had been made aware. The resident continued to experience symptoms, including increasing pain, nausea, vomiting, and dizziness, until she was eventually sent to the hospital, where she was diagnosed with a UTI caused by E. coli. Interviews with facility staff confirmed that the required assessments and notifications were not completed, and facility policies requiring identification, documentation, and reporting of UTI symptoms were not followed.