F0684

D

Failure to Monitor Vancomycin Trough Levels and Provide Appropriate UTI Treatment

Providence, Rhode Island Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services for a resident treated for a UTI with IV vancomycin, who later experienced a fall and was admitted to the hospital with sepsis. The resident had an unwitnessed fall and increased confusion in November 2025, prompting the NP to order blood work and a urine sample to evaluate for underlying causes. Two urine specimens collected by clean catch on consecutive dates were reported by the lab as suggestive of contamination, with instructions to repeat testing if clinically indicated. A subsequent provider order directed staff to obtain a urine specimen via straight catheterization every shift until obtained, and a specimen collected on 11/28/2025 later resulted positive for a UTI with two organisms at a colony count greater than 100,000.

Following the positive urine culture, the resident was started on antibiotic therapy, including IV vancomycin. The NP ordered vancomycin 1 g IV twice daily for 12 days, with instructions to monitor vancomycin trough levels before the fourth dose and to maintain a target trough range of 15–20 mg/L. The December MAR showed the resident received vancomycin from early to mid-December with dose adjustments based on trough levels. However, record review did not show evidence that vancomycin trough levels were obtained prior to each fourth dose on three separate dates, representing three missed opportunities to monitor levels as ordered. The first trough level was not obtained until 12/10/2025, at which time the level was 12.1 mg/L, below the desired therapeutic range, and the dose was then increased from 1 g to 1,250 mg.

Ten days after completion of the antibiotic course, progress notes documented that the resident sustained a fall, was bleeding from the genital area, appeared not at baseline, was shaky, unable to stand, and pale, and was transferred to an acute care hospital where the resident was admitted with sepsis. Hospital documentation indicated concern for sepsis with a urinary focus of infection, and the resident received broad-spectrum antibiotics, including vancomycin, along with fluids and blood. During interviews, the NP stated she expected staff to obtain vancomycin trough levels after the third dose and before the fourth dose to ensure therapeutic levels, acknowledged that trough levels were not completed on the three specified dates and that the 12/10/2025 trough was subtherapeutic. The DON was unable to provide evidence that the facility provided appropriate treatment and services for the resident diagnosed with a UTI who subsequently fell and was admitted for sepsis, and a pharmacy representative stated that subtherapeutic vancomycin trough levels increase the likelihood of failing to destroy an infectious organism.