Failure to Provide Timely and Appropriate UTI Care
Penalty
Summary
A resident with a complex medical history, including large B-cell lymphoma, myasthenia gravis, and polyuria, experienced ongoing symptoms suggestive of a urinary tract infection (UTI) for over a month. The resident repeatedly reported symptoms such as bladder pain, painful urination, and flank pain, and made multiple requests for a urine analysis (UA) to be completed. Despite these requests, there were significant delays and failures in obtaining and processing urine samples: the first UA was not sent to the lab, the second was not received or analyzed, the third was contaminated, and the fourth was not processed. Only the fifth UA was successfully analyzed, but it showed abnormalities, and no timely follow-up or re-collection was performed after a contaminated result was reported. Throughout this period, the resident continued to experience pain and discomfort, as documented in progress notes, and was administered pain medications such as ibuprofen and phenazopyridine. The resident also reported that their external catheter (Purewick) was unavailable due to a missing part, which had not yet been replaced. Despite ongoing symptoms and abnormal UA findings, there was no evidence that a provider assessed the resident in response to these concerns until much later, after the Medical Director reviewed the case. The resident and their power of attorney repeatedly sought information and action regarding the UTI symptoms, but communication and follow-up were inadequate. Interviews with facility leadership, including the Director of Nursing and Infection Preventionist, confirmed that there was no documentation of provider follow-up for the resident's UTI symptoms and that multiple urine samples were not processed by the lab. The facility's own policy states that residents have the right to receive adequate and appropriate care, be informed of changes in their medical condition, and participate in their own care planning. These rights were not upheld in this case, as the resident's symptoms were not appropriately or promptly addressed.