IDPH has cited and fined Lemont Nursing & Rehabilitation Center nursing home in Lemont due to the failure of the staff to notify the resident’s doctor of abnormal lab results.
One of the basic facts of care in a nursing home is that there are not doctors on hand on a 24-7 basis. However, members of the nursing staff are, and one of their functions is to serve as “the eyes and ears of the doctor” when the doctor is not actually in the nursing home. Nurses are required to notify the doctor of significant events in the care of the resident, such as the occurrence of a fall, the development or a bed sore or its decline, abnormal lab or test results, and of any changes in the condition of a resident.
One thing that requires physician notification is the onset of signs and symptoms of infection. Nurses are not required to be able to determine exactly what the infection is or how to treat the infection, but they do need to know when a resident is showing signs and symptoms of infection. When a resident is showing signs and symptoms of an infection, the nurse is required to notify the doctor and the doctor can use that information to decide whether to issue orders for treatment over the phone, come into the nursing home to examine and treat the resident, or to have the resident sent to the emergency room.
The use of an indwelling catheter is something that predisposes nursing home residents to develop urinary tract infections. There are a number of reasons for this, and as a general proposition, nurses working in a nursing home setting are well-schooled on what the signs and symptoms of a urinary tract infection are. These might include: lethargy, confusion or other changes in mental status; fever; back or flank pain; burning while urinating; and changes in the color or appearance of the urine itself such as it becoming cloudy or darker, having pus or blood in it, or having a foul odor. When those signs and symptoms occur, then physician notification is required.
The resident at issue here had an indwelling catheter. He began to show increased confusion and the urine draining from catheter was cloudy. These are signs of a urinary tract infection. The physician was notified and he ordered a urinalysis and urine culture to determine whether the resident was suffering from a urinary tract infection and if so, what antibiotics would be most effective against it.
The resident also had a regularly scheduled Complete Blood Count (CBC) done the next day. When the results of that came back that afternoon it showed that the white blood cell count was significantly elevated. An elevated white blood cell count is an indicator that there is an infection present. This abnormal lab result should have been reported to the doctor. However, it was not. In the context of this resident’s reported confusion and cloudy urine, the failure of the nursing staff to notify the doctor of the abnormal lab results deprived the doctor of a critical piece of information in medical decision-making.
Three days after the CBC test results came back, the results of the urinalysis came back. These showed that the resident did in fact have a urinary tract infection. The doctor was properly notified and started the resident on an antibiotic. However, the following day the resident had to be sent to the hospital due to decreased urine output. The resident was admitted to the intensive care unit with a diagnosis of elevated white blood cell count and sepsis. After the family had the resident placed on comfort care only, the resident died a week later.
Here, there was a simple failure to follow standard nursing practices. The doctor was notified when there was a change in the resident’s condition initially, resulting in the urinalysis being ordered. The doctor was also notified when the results of that test came back with abnormal findings. However, the staff failed to notify the doctor of the blood test showing the elevated white blood cell count. This piece of information would likely have led to early administration of antibiotics and may have yielded a different outcome, as delay in the initiation on effective antibiotics increases ill-effects of infections.
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