Failure to Monitor and Document UTI Symptoms and Antibiotic Effectiveness
Penalty
Summary
The facility failed to adequately monitor and assess for signs and symptoms of urinary tract infections (UTIs) and to document the effectiveness and potential adverse reactions to antibiotics for two residents who experienced a change in condition. For one resident with impaired cognition, frequent incontinence, and a history of lumbar fracture and encephalopathy, there was an order for a urinalysis and culture, but the resident's family opted for outside testing. Upon return with a UTI diagnosis and an order for oral antibiotics, the resident's records lacked evidence of consistent monitoring for UTI symptoms beyond vital signs, such as changes in incontinence, burning, odor, or frequency, and did not consistently document monitoring for antibiotic side effects. Another resident, with diagnoses including congestive heart failure and depression, was also identified as frequently incontinent of bladder. After being diagnosed with a UTI and prescribed a five-day course of oral antibiotics, the resident's documentation did not indicate what UTI symptoms were present or provide consistent notes on the presence, increase, or decrease of symptoms, nor on any side effects from the antibiotic. There was no clear documentation to determine if the resident's urinary symptoms had resolved or if the antibiotic was effective after the treatment course. Interviews with nursing staff and the DON confirmed that facility policy requires documentation of UTI symptoms, vital signs, and any adverse reactions to antibiotics every shift following a UTI diagnosis. However, the records for both residents lacked this required documentation, including initial symptoms, provider notifications, and follow-up monitoring. The facility's own policies on change in condition and UTI management were not followed, as assessments, interventions, and resident responses were not consistently recorded in the medical record.