Failure to Notify Responsible Party of UTI Diagnosis and Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a change in condition, specifically a newly identified urinary tract infection (UTI) and initiation of antibiotic treatment. The resident was an adult female with dementia, depression, muscle weakness, a cognitive communication deficit, and a documented need for assistance with personal care. Her MDS assessment showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The admission record identified a family member as the resident’s POA for care, first emergency contact, and responsible party. During an interview, this family member reported that the facility had not been consistently notifying her of changes in the resident’s condition and that she only learned of the UTI treatment when the resident mentioned she was receiving “shots” during a visit. Record review showed that on a specified date, the physician evaluated the resident’s urine after a nursing request and documented pyuria, bacteriuria, and a urine culture with more than 100,000 organisms of Proteus mirabilis, sensitive to Rocephin. The physician’s plan included Rocephin 1 g IM daily, and an order was entered for ceftriaxone IM once daily for five days for UTI. Nursing notes documented administration of IM antibiotic injections on multiple days with no adverse reactions. However, there was no documentation in the medical record that the responsible party was notified of the abnormal lab findings, confirmed UTI, or new antibiotic orders. The administrator confirmed the facility could not locate documentation of such notification, and both an LPN and an RN stated in interviews that for cognitively impaired residents or those who are not their own responsible party, the resident representative should be notified of newly identified infections, changes in condition, new physician orders, and abnormal lab results.
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