Failure to Provide Timely UTI Assessment and Care
Penalty
Summary
A deficiency occurred when a resident who reported symptoms of a urinary tract infection (UTI) did not receive timely assessment, treatment, or care in accordance with professional standards, the care plan, and her expressed preferences. The resident, who had a history of hypertension, type 2 diabetes, stroke, amputation, and progressive neurological conditions, reported to staff that she was experiencing frequent urination and burning sensations. Despite informing a nurse of these symptoms, there was no documentation in the resident's progress notes, 24-hour report, or physician orders regarding her complaint or any follow-up actions. Multiple staff interviews revealed a breakdown in communication and documentation. The charge nurse for the 2-10 shift stated she was not informed of the resident's symptoms or any change in condition, and the LVN who was told of the symptoms did not document the complaint, notify the charge nurse, or follow through with obtaining a urine specimen as ordered by the primary care provider. The Assistant Director of Nursing (ADON) was also unaware of the resident's change in condition and only became aware when laboratory personnel requested a urine specimen that had not been collected. The facility's policy required immediate physician notification and documentation for significant changes in status, which was not followed in this case. The lack of timely assessment, documentation, and follow-up resulted in the resident not receiving appropriate care for her reported UTI symptoms. The failure to act according to physician orders, facility policy, and professional standards of practice led to a delay in diagnosis and treatment for the resident.