Failure to Communicate Lab Results and Assess Changes in Condition Leads to Delayed Treatment and Hospitalization
Penalty
Summary
The facility failed to provide timely communication of urinalysis and urine culture results to a resident's urologist, which resulted in a significant delay in treatment for a urinary tract infection (UTI). The resident, who was nonverbal and had a complex medical history including hemiplegia, stroke, neurogenic bladder, and prostate cancer, had a physician's order for increased fluid intake and monitoring for UTI symptoms. However, there was no documentation that the order was followed or reflected in the care plan, and the urinalysis and urine culture results were not promptly sent to the urologist as required. The urologist did not receive the results until ten days after they were available, which led to a lack of timely antibiotic treatment and escalation of the resident's condition. The resident subsequently experienced a decline, including pain, discomfort, and ultimately required transfer to the emergency room, where he was diagnosed with a UTI and sepsis. He received IV hydration, antibiotics, and underwent invasive procedures such as a PICC line insertion and intubation. Documentation revealed that staff failed to reassess the resident for warning signs of sepsis after readmission and did not complete change in condition documentation, including current vital signs and assessments, on multiple occasions prior to the resident's deterioration. The lack of timely and thorough assessment and communication contributed to the resident's progression to septic shock and cardiac arrest, necessitating emergent CPR. A second resident was also identified as not having proper assessment or documentation during a change in condition, specifically lacking current vital signs and respiratory assessment prior to hospital transfer for pneumonia. Facility policies required prompt reporting of diagnostic results and thorough documentation during changes in condition, but these were not followed. Interviews with facility staff, including the DON and NP, confirmed expectations for timely communication and documentation, which were not met in these cases.