Failure to Notify Former Resident of Post-Discharge UTI Diagnosis
Penalty
Summary
The facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection (UTI) after the resident had left the facility against medical advice (AMA). The resident, who was cognitively intact and had an indwelling catheter, was admitted with diagnoses including retention of urine and presence of urogenital implants. During the resident's stay, intermittent confusion was observed, prompting a physician order for a urinalysis and culture. The urine sample was collected and sent to the laboratory, but before the results were available, the resident chose to leave the facility AMA. The laboratory results, which were received after the resident's departure, indicated a significant growth of Escherichia coli, confirming a UTI. Review of the medical record showed no documentation that the resident or their representative was notified of these abnormal results. Interviews with the Administrator, DON, and Unit Manager confirmed that there was an expectation to notify former residents of such findings, but no evidence of notification or attempts to contact the resident was found in the record. Facility policies required notification of changes in condition and post-discharge follow-up, but these were not followed in this case.