Failure to Implement Ordered IV Antibiotic Therapy for UTI
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a diagnosed urinary tract infection (UTI) received the ordered antibiotic treatment. The resident, who had diagnoses including a UTI of unspecified site and unspecified urinary retention, had a history of UTIs as reported by her son, who stated she had experienced two UTIs since admission. A provider encounter note documented that the resident complained of fatigue, generally not feeling well, and that her urine in the catheter had become progressively more cloudy. The provider assessed her as having a complicated UTI with multidrug-resistant Pseudomonas, previously shown to be sensitive to cefepime and Zosyn, and planned to start cefepime 1 gram IV every 12 hours once IV access (PICC or peripheral) could be established and maintained for seven days. Record review showed no documentation in the progress notes regarding whether IV access was ever obtained, and the physician’s orders contained no order for cefepime corresponding to the provider’s plan. Instead, the only antibiotic order identified was for cephalexin 250 mg orally once daily for UTI suppression, which the resident received from mid-August through early October. The medication administration records confirmed that the resident did not receive any doses of IV cefepime. During interview, the Regional Clinical Nurse confirmed there was no documentation of the resident going out for PICC or IV access and that the resident did not receive any IV cefepime as indicated in the provider encounter note.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.