Delayed Response to UTI Symptoms and Urine Analysis Order
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) reported symptoms including frequent urination and burning, which she stated had been present for a couple of days. The resident communicated her symptoms to nursing staff, and a nurse practitioner assessed her and ordered a urine analysis (UA) and labs to evaluate for a UTI. However, the order for the UA was not entered into the physician orders by the responsible LPN until two days later, and the UA was not collected at the time it was initially ordered. The resident continued to report symptoms and was seen again by the nurse practitioner, who reiterated the need for a UA, but the test was still not promptly obtained. On the day the UA was finally collected, the resident experienced a significant drop in oxygen saturation and heart rate during the process, requiring intervention by respiratory therapy and nursing staff. Shortly after, the resident exhibited altered mental status, and the physician was notified. The resident was subsequently sent to the hospital, where she was diagnosed with acute UTI, bacteremia, and acute kidney injury, and required intravenous antibiotics and hospitalization. The UA that was eventually collected was not sent to the lab due to the resident's transfer to the hospital. Interviews with facility staff confirmed that the initial order for the UA was not entered or acted upon in a timely manner, and staff could not provide a reason for the delay. The resident expressed dissatisfaction with the response to her complaints and believed that her condition worsened due to the delay in obtaining the UA. The facility's policy referenced following clinical guidelines for identifying UTIs but did not specify what those guidelines were.