Delayed UTI Management and Incontinence Care Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment for a resident with signs and symptoms of a urinary tract infection (UTI). One resident with cognitive impairment, severe physical impairment, and total dependence for ADLs was care planned for bowel and bladder incontinence with interventions to keep the skin clean and dry. Progress notes documented that the resident exhibited behavioral changes, including agitation, hallucinations, altered mental status, and complaints of burning pain with urination. A physician order was obtained to perform a urine dip and notify the physician, but the urine dip ordered on 12/16/25 was not obtained as scheduled. Subsequent documentation showed that the urine dip was not actually completed until several days later, when the resident was straight catheterized and a urine dip revealed positive nitrites, leukocytes, and blood, consistent with a UTI. An antibiotic was then started, and a UA with culture and sensitivity was ordered. The unit manager RN later confirmed that the resident had signs and symptoms of a UTI on 12/15/25 and that the urine sample was not collected and sent out until six days later, stating that the specimen should have been collected and sent immediately. The resident’s daughter reported that in December the resident had UTI symptoms and was not started on an antibiotic for six days, and that staff had told her the resident was at baseline and did not have a UTI. The deficiency also includes failure to provide timely incontinence care for another resident with intact cognition, a colostomy, spinal stenosis, weakness, and inability to control bowel or bladder. This resident’s care plan called for staff assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene with brief changes. Surveyors observed the resident’s call light on and, upon interview, the resident stated he had turned it on because he was wet and needed changing and that staff did not always respond timely. The call light remained on for 41 minutes before a CNA entered to provide incontinence care, at which time the resident’s brief was full of urine. The CNA and the DON both acknowledged that 41 minutes was too long for a call light to remain unanswered for a resident needing staff assistance.
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