Delay in Antibiotic Administration Following Positive UTI Result
Penalty
Summary
A female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs) was not administered her prescribed antibiotic, Bactrim, in a timely manner following a positive urine culture indicating a UTI. The resident reported dysuria to the medical doctor, who ordered a urinalysis. The urine specimen was collected and results indicated a high microbial load of Escherichia coli. Despite this, there was a delay of seven days before the resident received her prescribed antibiotic treatment. The medication administration record (MAR) showed that the resident received only one dose of Bactrim initially, with no further doses administered until several days later, and there was no documentation explaining the gap in administration. Interviews with nursing staff revealed uncertainty and lack of recall regarding the delay, with staff acknowledging that the standard process would be to notify the nurse practitioner and obtain orders promptly upon receiving lab results. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The resident reported experiencing increased pain and dysuria during the period she did not receive her antibiotics, expressing concern about potential kidney damage. Staff interviews confirmed that the delay in starting antibiotics was not in line with expectations and that the nurse practitioner should have been notified within 24 hours of positive lab results. The facility administration acknowledged that the situation did not meet their standards and could not explain how the error occurred.