Failure to Follow Psych NP Recommendation and Identify UTI in Resident with Behavioral Changes
Penalty
Summary
Facility staff failed to follow the recommendation of a psychiatric nurse practitioner to rule out underlying medical causes, specifically a urinary tract infection (UTI), in a resident with dementia who exhibited increased anxiety, agitation, and aggression. The psych NP had documented that the resident had a history of significant agitation in the presence of acute medical issues, particularly UTIs, and advised that if behavioral changes persisted, a repeat urinalysis should be considered. Despite ongoing behavioral changes, the medical record showed that a repeat urinalysis was neither considered nor obtained as recommended. The resident continued to display behavioral disturbances, including verbal aggression toward another resident, and was later transported to the hospital by family due to concerns about a change in mental status. Hospital records confirmed the presence of sepsis due to Enterobacter species, with bacteremia secondary to a UTI, and the resident was started on intravenous antibiotics. The Director of Nursing later acknowledged being unaware of the psych NP's recommendation and confirmed that the repeat urinalysis had been missed.