IDPH has cited and fined Champaign Urbana Nursing & Rehab nursing home in Savoy after a resident there had a urinary tract infection go untreated for over a week due to the failure of the nursing staff to timely notify the resident’s doctor of changes in the resident’s condition and carry out orders for a urine culture.
When it comes to the relationship between nurses and doctors in a nursing home setting, nurses are responsible carrying out two major functions. First, because doctors are not present in the nursing home on a 24/7 basis, they must serve as the “eyes and ears” of the doctor and report changes in the resident’s condition, including the presence of signs and symptoms of infection. Second, nurses must timely carry out orders by the doctor for treating the resident.
The presence of a urinary catheter places a resident at increased risk for developing a urinary tract infection. There are a number of reasons for this, including the fact that the presence of the catheter opens up the body for entry of infecting organisms; bacteria can colonize the catheter itself; and the placement of the catheter can cause trauma to the urinary tract and/or obstructions to the outflow of urine. Because the risk of urinary tract infections is increased, their use is discouraged by federal regulations. Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan.
Nurses are not required to be able to diagnose urinary tract infections or determine how to treat them, but they do need to know and be able to identify signs and symptoms of a urinary tract infection. These may include: burning while urinating; foul-smelling, cloudy, or bloody urine; back or flank pain; mental status changes such as confusion or delirium; fever; and weakness or lethargy. When a resident demonstrates signs and symptoms of a urinary tract infection, the nurse must notify the doctor who then must decide whether to order treatment over the phone, come to the nursing home to evaluate the resident, or send the resident to the emergency room.
The resident at issue had an enlarged prostate. This caused him to experience urinary retention which is a risk factor for developing urinary tract infections. To alleviate the urinary retention, use of a catheter was ordered. The risk of developing a urinary tract infection was something that was specifically addressed in the resident care plan and physician orders.
The resident initially developed signs and symptoms of a urinary tract infection in the form of a fever and pain and burning with urination during the early morning hours on a Saturday. The doctor was properly notified and ordered a urinalysis and culture and sensitivity test. The nurse collected the urine sample. However, the lab with whom the facility had a contract did not do pick ups on the weekend, so it was not brought to the lab until Monday.
When the results of the urinalysis were returned that same Monday, the nurse called the results over to the doctor. However, the culture and sensitivity results were not available, so the doctor did not order any antibiotics. Those results were not received until Wednesday. However, no one called the doctor to inform him of the results of the the culture and sensitivity. Usually, this testing is used to help determine what antibiotics the infection is susceptible to. Without those results, there were no antibiotics ordered.
On Friday (one week after the signs and symptoms of the infection first appeared), the resident complained of painful urination which was producing bloody, cloudy, foul-smelling urine. These are all signs of a urinary tract infection. The nurse on duty called the nurse practitioner who ordered a urinalysis and culture and sensitivity. However, given that this was a Friday and the lab had already come for the day, the nurse put in the order for the testing to be done the next day that the lab was in the building which would be the following Monday.
The urine culture was done the following Monday and the results arrived on Tuesday. Based on the results, the nurse practitioner ordered an antibiotic for the resident. However, the resident’s condition continued to decline, and he was brought to the emergency room two days after starting the antibiotic suffering from severe sepsis. The infectious disease specialist noted that the resident had been having pain with urination for two weeks and that the catheter appeared to be infected. The resident was sent to the Intensive Care Unit due to the severity of the infection.
There were a number of shortcomings in the care that this resident received leading to him developing severe sepsis requiring the admission to the Intensive Care Unit:
- Neither the doctor nor the nurse practitioner were informed that the urine sample they ordered taken could not be delivered to the lab until the following Monday.
- The doctor was not informed of the result of the culture and sensitivity, delaying the start of antibiotic therapy.
- The catheter was described as having an infected appearance, indicating that there was poor catheter care throughout.
- The resident doubtless continued to have signs and symptoms of the a urinary tract infection after the signs first appeared, but there were only two notifications made to medical providers outside the nursing home.
All of these delayed the start of effective care for the urinary tract infection, resulting in the resident to experience such severe sepsis. It is well-established that early intervention in an infection helps yield better outcomes and prevents the worsening of the infection into the kind of severe sepsis that this resident experienced. Multiple chances a better outcome were let go by the wayside.
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