IDPH has cited and fined Heartland of Galesburg after a resident there died due to sepsis brought on by an untreated urinary tract infection.
One of the basic truisms of care in a nursing home setting is that doctors are not there on a 24/7 basis. Because of this, nurses must be the “eyes and ears” of the doctors and let them know when there has been a change in the condition of a resident. The nurse does not need to know what the change represents (though they often have a good idea) or how to treat it. It is up to the doctor to make a diagnosis and decide how to treat the resident. The nurse simply needs to be able to identify the change in condition, notify the resident’s physician, and give the doctor sufficient information for the doctor to make good decisions.
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. There must be medical justification for the use of a catheter in a nursing home, including a physician order for it. Nursing homes are required to evaluate the use of a catheter on an ongoing basis and obtain orders for its removal when possible. Catheter care, including monitoring for signs and symptoms of urinary tract infections, must be addressed in the resident care plan. A well-done care plan will include monitoring for signs and symptoms of infection.
Nurses must 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 (usually in the form or ordering a urinalysis and prescribing an antibiotic), come to the nursing home to evaluate the resident, or send the resident to the emergency room. Left untreated, a urinary tract infection can cause sepsis leading to multi-organ failure and death.
The resident at issue was admitted to the nursing as a short-term admission to undergo rehabilitation after suffering a nondisplaced hip fracture at home (i.e., one that did not require surgery). While she was in the emergency room, the staff there placed a catheter so that she would not have to get up to urinate. Before that, there was no need for a catheter. When she was transferred to the nursing home the following day, the catheter was left in place. However, there were no orders entered for the use of the catheter and no assessment made of the suitability of removing the catheter.
Just over a week after the resident was admitted to the nursing home, the nurses noted on consecutive days that the resident had cloudy urine. This is one of the signs of a urinary tract infection. However, there was no notification of the doctor. There were two additional days in which there was no note at all. However, aides told the state surveyor that in the interim, the urine had gained a foul odor and that there was
On the afternoon of the fourth day after the urine turned cloudy, the resident became lethargic. It was recognized by the physical therapist, who reported it to the nurse on duty. The nurse also noted that the resident was less talkative. That evening, the nurse on duty also noted that the resident was lethargic, so she sent a fax to the resident’s doctor at 9:40 p.m. Because the information was faxed to the doctor rather than the subject of a phone call, the doctor was not aware of the change in condition until the resident was already in the hospital the following afternoon.
Over the next day, the resident continued to decline until by early afternoon, the nurse on duty called 911 to have the resident transferred to the hospital. The paramedics report stated that the resident had been sick since the day before and became unresponsive in the morning. Upon arrival at the hospital, the resident was obviously ill – her appearance was described as “toxic”. The collection bag for the catheter was described as being filled with dark brown urine with clumps of pus in it. The urine was foul-smelling to the point that it made the nurse in the emergency room nauseous. The catheter was changed out, but very little urine came out once the new catheter was placed. This was an indication that the resident was in kidney failure due to sepsis.
The resident passed away approximately 12 hours after arriving in the emergency room. Cause of death was multi-organ failure due to sepsis from the urinary tract infection.
There were multiple failures in the care of this resident that led to her death:
- The nursing home allowed the resident to remain catheterized without a physician’s order for it use;
- The nursing home allowed the resident to remain catheterized when there was no medical justification for the use of the catheter;
- There was no assessment as to whether the resident’s condition actually required the use of a catheter;
- The care plan for the use of the catheter included monitoring the resident for signs and symptoms of infection and notifying the physician of the onset of such. This was not done;
- Failed to notify the physician of the initial development of cloudy urine, which would have likely led to a urinalysis being done – and just as likely, an order for the removal of the catheter, since the doctor was familiar with the patient outside the nursing home and knew that she did not need a catheter;
- Failed to recognize the development of a foul odor to the urine and the presence of pus in the urine – clear markers of infection;
- Failed to report the onset of lethargy to the doctor to the doctor when it was reported by physical therapy;
- When the staff finally notified the doctor of the onset of the change in condition, they did so by fax rather than calling the doctor, resulting in the doctor not receiving the communication from the nursing home;
- Failed to notify the doctor the morning that the resident was transferred to the hospital of the declines that occurred overnight; and
- The nursing home did not have policies and procedure in place regarding catheter use and care.
Ordinarily urinary tract infections are easily treated with antibiotics. However, when there are substantial delays in the treatment of a urinary tract infection and can lead to sepsis, multi-organ failure, death – as happened here. There were many opportunities for this tragic outcome to be avoided and to allows this resident to return home. Sadly, they were all missed, over a period of several days and multiple shifts.
One of our basic beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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