Failure to Timely Identify and Treat Urinary Tract Infections
Penalty
Summary
The facility failed to timely identify and treat urinary tract infections (UTIs) for two residents, resulting in deficiencies related to the management of urinary health. For one resident with vascular dementia and a history of urinary tract infections, a urine specimen was collected as ordered, but the results were not completed or reported to the physician or nurse practitioner. The specimen, collected on a Friday, was likely discarded because the lab did not pick up specimens on weekends, and it was not resent. There was a significant delay before a new specimen was collected and processed, during which time the resident did not receive appropriate follow-up for potential infection. Another resident with multiple sclerosis, diabetes, and a neurogenic bladder had an indwelling catheter and was at risk for catheter-associated complications. This resident exhibited confusion, prompting an order for a urine specimen. The initial specimen was collected and reported as probably contaminated, with a recommendation to repeat the test. However, there was no evidence that a repeat specimen was collected or sent to the lab as ordered. Documentation was lacking regarding the collection and handling of urine specimens, and the resident subsequently experienced discomfort, required catheter replacement, and was hospitalized with a diagnosis of UTI and sepsis. Both cases demonstrated failures in following up on laboratory results, ensuring timely specimen collection, and maintaining adequate documentation. The deficiencies were compounded by changes in medical staff and poor communication, resulting in lapses in care for residents with significant urinary health risks.