Failure to Obtain Ordered Urology Consult for Resident With Recurrent UTIs
Penalty
Summary
The facility failed to ensure that a resident received a urology consultation as ordered following hospitalization for sepsis due to urinary tract infection (UTI). The resident had multiple sclerosis (MS), neuromuscular dysfunction of the bladder, and required an indwelling urinary catheter due to urinary retention. Hospital records from a stay ending on 12/19/25 documented that the resident was discharged back to the facility with an order for referral to a urologist. The resident’s power of attorney reported concerns about multiple UTIs and hospitalizations and stated that the resident was supposed to see a specialist but that she never received any update from the facility. A registered nurse stated that the local urology office did not accept the resident’s insurance and acknowledged that neither the physician nor the family were notified that the urology consultation ordered on 12/19/25 did not occur. The director of nursing confirmed that the resident had recurrent UTIs requiring hospitalizations and should have been referred to a urologist for bladder management and ongoing care due to these recurrent infections, but this referral and evaluation were not completed.
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