Delayed UTI Treatment and Failure to Update Incontinence Care Plan
Penalty
Summary
The facility failed to ensure timely initiation of antibiotic treatment and appropriate care planning for a resident with signs and symptoms of a urinary tract infection (UTI). The resident had chronic kidney disease, hypertensive chronic kidney disease, bladder incontinence related to impaired mobility, and was undergoing cancer treatments with a compromised immune system. The facility’s algorithm for antimicrobial management of UTIs required treatment when new or marked incontinence, suprapubic pain, hematuria, and other symptoms were present, and the resident’s care plan directed staff to monitor and document for UTI signs such as pain, burning, blood-tinged urine, foul-smelling urine, and changes in behavior or eating patterns. On one date in December, the nurse practitioner assessed the resident, who complained of fatigue, cough, and suprapubic pain, and ordered a urinalysis. The following day, nursing documentation showed hematuria and suprapubic pain, and the urinalysis revealed dark brown urine, extra turbid clarity, protein, blood, and leukocytes. Over the next days, nursing notes documented dark brown, odorous urine, suprapubic pain, dysuria, and incontinence, and the urine was sent for culture and sensitivity. The final culture, completed several days later, showed ESBL-producing Klebsiella pneumoniae and Proteus mirabilis, and the resident was placed on contact isolation. However, the nurse practitioner stated she waited for culture results before starting antibiotics and was not informed that additional symptoms and worsening signs were being documented by nursing staff. The nurse practitioner ordered Levaquin after reviewing the culture results, and the first dose was administered approximately seven days after the resident’s urinary symptoms were first identified and more than 28 hours after the positive ESBL culture result was reported. During this period, the resident experienced suprapubic pain, burning with urination, blood and odor in the urine, and incontinence of dark brown odorous urine. The resident’s family member reported that the resident was not being cleaned adequately, sat in soaked incontinence briefs for too long, and required more help toward the end of her stay. The Minimum Data Set assessments showed a decline from supervision/touching assistance for toileting and hygiene to dependence and substantial/maximal assistance for toilet transfers, but the care plan at discharge did not reflect increased care needs for toileting, hygiene, or UTI monitoring. The DON confirmed the resident had a rapid decline after the December UTI, that care plan interventions for incontinence and toileting were not updated to match her increased dependence, and that there was no documentation to show the change in condition or altered incontinence care and monitoring needs.
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