Failure to Provide Adequate Incontinence and UTI Prevention Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent urinary tract infections (UTIs) for a resident with a history of recurrent UTIs, chronic kidney disease, and urinary incontinence. The resident was always incontinent of urine, required substantial to maximum assistance for toileting hygiene, and was dependent on staff for activities of daily living. The care plan included interventions such as monitoring for signs and symptoms of infection, encouraging fluids, and providing proper perineal care with each incontinence episode. However, documentation and interviews revealed lapses in monitoring, reporting, and timely response to changes in the resident's condition. Despite ongoing antibiotic therapy for a recent UTI, the resident continued to report symptoms such as burning and stinging upon urination and expressed concerns that the infection was still present. Staff interviews indicated that standard practice included toileting every two hours, encouraging fluids, and monitoring for behavioral or urinary changes. However, there were instances where changes in the resident's mental status, increased confusion, and reports of burning upon urination were not promptly communicated or acted upon. The resident was left in her wheelchair all night, and staff failed to notify the nurse of changes in her condition in a timely manner. Progress notes and late entries documented that the resident experienced increased confusion, unusual behavior, and eventually became unresponsive with emesis, leading to her transfer to the hospital for further evaluation. The facility's policies required regular assessment, monitoring, and individualized care planning for incontinence management, but these were not consistently implemented. The lack of timely identification and reporting of UTI symptoms and inadequate incontinence care placed the resident at risk for ongoing infection and related complications.