Failure to Notify Physician of Positive ESBL Urine Culture Result
Penalty
Summary
The facility failed to notify a resident's attending physician of a urine culture result that identified the presence of ESBL in the resident's urine. The medical record review showed that a urine culture was obtained as ordered, and the result, which indicated ESBL and recommended contact precautions, was verified and printed. However, there was no documentation that the physician was notified of this result until over two weeks later, when a nurse documented contacting the physician after being informed by an outside physician's office that a scheduled surgery could not proceed due to untreated ESBL. The nurse then obtained an order to change the Foley catheter and collect a new urine sample. This lack of timely physician notification and follow-up on the positive ESBL result led to a delay in treatment and the postponement of a scheduled ureteroscopy with stone removal. The resident ultimately received the procedure nearly a month later than originally planned. The Nursing Home Administrator confirmed that there was no documentation of physician notification at the time the initial lab result was received.