Failure to Timely Assess and Intervene for UTI Symptoms
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a urinary tract infection (UTI). The resident, who had moderate cognitive deficits and was totally dependent on staff for activities of daily living, reported burning with urination and had a history of incontinence and previous UTIs. Despite the family reporting symptoms to nursing staff on a weekend, no urinalysis (UA) was ordered until six days later. Staff responses included monitoring and providing peri care, but there was no documentation of vital signs or nursing notes during the period when symptoms were reported. The resident's chart lacked nursing progress notes from several days and no vital signs were recorded for over a week, despite the resident exhibiting symptoms consistent with a UTI. Interviews with staff revealed that communication breakdowns occurred between staff and the resident's family, and that staff did not escalate the resident's symptoms to a physician or obtain a UA in a timely manner. The facility's policy required documentation, assessment, and follow-up for changes in condition, including full vital signs and nursing notes, but these were not completed. The deficiency was identified through observation, interview, and record review, confirming that the facility did not follow its own protocols for assessment and documentation when a resident exhibited a change in condition.