Delay in Practitioner Notification and Antibiotic Administration Following Positive UTI Lab Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results that were outside clinical reference ranges, specifically in the case of a female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs). After the resident reported dysuria, a urine sample was collected and later confirmed to be positive for a UTI with a high microbial load of Escherichia coli. Despite the positive lab results, there was a delay in notifying the practitioner and obtaining an order for antibiotics. The resident did not receive her prescribed antibiotic, Bactrim, until seven days after the positive UTI results were received. Documentation showed that only one dose was administered initially, with a gap of several days before the full course of antibiotics was started. There was no documentation explaining the delay or the missed doses during this period. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the nurse responsible for receiving lab results did not promptly notify the practitioner or obtain timely orders. The resident reported experiencing increased pain and dysuria during the period she was not receiving antibiotics. Staff interviews indicated that the delay was not in line with facility policy, which requires medications to be administered in a safe and timely manner as prescribed. The failure to promptly communicate lab results and administer prescribed medication resulted in the resident not receiving the intended therapeutic benefit in a timely manner.