Failure to Implement Physician Orders and Timely Care for Suspected UTI
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident who had multiple diagnoses, including toxic encephalopathy, obstructive and reflux uropathy, and depression. The resident, who had an indwelling urinary catheter and required maximal assistance with activities of daily living, complained of pain and weakness. Although staff notified the medical doctor, the order to collect a urine sample to test for a urinary tract infection (UTI) was not carried out by the registered nurse. The order was not entered into the resident's medical record, and there was no documentation of a change in condition at the time of the complaint. This lapse resulted in a two-day delay in obtaining the urine sample and, consequently, a delay in the resident's care and treatment for a suspected UTI. The facility's policies required prompt assessment, documentation, and implementation of physician orders upon changes in a resident's condition, which were not followed in this instance. The deficiency was identified through interviews and record reviews, confirming that the required interventions were not implemented as per the facility's protocols.