AVON, IN - Federal inspectors found that Countryside Meadows nursing facility failed to provide timely medical care for a resident with a urinary catheter, resulting in a fatal infection that progressed to kidney failure and sepsis.
Critical Delays in Laboratory Testing and Treatment
The most serious violation occurred when staff failed to properly handle urgent laboratory orders for a long-term care resident who showed clear signs of a urinary tract infection. The resident, identified as Resident F, had a suprapubic catheter due to neurological bladder dysfunction and a history of stroke-related paralysis and Alzheimer's disease.
When nursing staff noticed purulent drainage around the catheter site and increased confusion on a Friday afternoon, a nurse practitioner ordered immediate STAT laboratory tests including blood work and urinalysis. However, critical communication breakdowns and procedural failures led to dangerous delays in processing these urgent tests.
The laboratory company's timeline revealed significant problems with the emergency testing process. Although the STAT order was received at 2:54 p.m., a lab technician attempted to contact the facility at 7:03 p.m. to inform them that no technician would be available until the next morning. The documentation noted that "nurse didn't answer page," indicating the facility missed this critical communication.
The urine sample, which should have been processed within four hours according to the laboratory contract, wasn't collected by the lab until 7:33 a.m. the following day - nearly 16 hours after collection. Laboratory results showing signs of infection weren't available until late the next morning, and the culture confirming Proteus mirabilis bacteria wasn't reported until Monday at 10:39 a.m.
Medical Consequences of Treatment Delays
The delays in laboratory processing and treatment initiation had severe medical consequences. Urinary tract infections in catheterized patients can rapidly progress to more serious conditions when left untreated. The resident's infection advanced from a localized urinary tract infection to urosepsis - a life-threatening condition where bacteria from the urinary system enter the bloodstream.
This progression led to acute kidney failure and systemic inflammatory response syndrome (SIRS), a dangerous condition where the body's immune response causes widespread inflammation. The resident's kidney function deteriorated rapidly, with blood urea nitrogen (BUN) levels rising from normal to critically high levels above 100, indicating severe kidney dysfunction.
When catheter-associated urinary tract infections occur, immediate laboratory testing and prompt antibiotic treatment are essential to prevent systemic complications. The bacteria identified in this case, Proteus mirabilis, is particularly problematic in catheterized patients because it can form biofilms on catheter surfaces and cause rapid clinical deterioration.
Inadequate Monitoring During Critical Period
Beyond the laboratory delays, inspectors found significant gaps in patient monitoring during the critical weekend period. Medical records showed no documented vital signs or resident assessments on Saturday or Sunday, despite clear signs of infection having been identified on Friday.
The facility's care plan specifically required staff to monitor for urinary tract infection symptoms including confusion, back pain, fever, and changes in urine appearance. However, when the resident complained of severe back pain reaching 9 out of 10 on multiple occasions, there was no documentation that the physician was notified as required by the care plan.
Additionally, after purulent drainage was noted around the catheter insertion site, there was no documentation of ongoing assessment or monitoring of the catheter system throughout the weekend. This represents a critical oversight in catheter care protocols, which require regular monitoring for signs of infection or mechanical problems.
Communication Failures With Family
The inspection revealed concerning communication patterns with the resident's family. According to witness statements, the family member received a phone call asking to confirm do-not-resuscitate orders because the resident "had an infection and experienced a change in condition." However, the family member reported being unaware that the resident was being treated for an infection or that his condition had deteriorated so severely.
This communication breakdown is particularly significant because the resident's advance directive specified full interventions including life support measures and intensive care unit treatment. The directive explicitly stated preferences for hospital transfer when indicated to meet medical needs, yet the family was not informed of the developing crisis in time to make informed decisions about care.
Documentation and Record-Keeping Violations
Separate from the main incident, inspectors identified systematic problems with medical record documentation. Staff failed to properly document blood glucose monitoring results for a diabetic resident, missing recordings on multiple dates despite physician orders requiring testing every six hours.
The facility's policy required blood glucose results to be documented on monitoring tools or medication administration records, but staff had discontinued quality assurance procedures to identify missing documentation. This represents a broader pattern of inadequate attention to documentation requirements that are essential for patient safety monitoring.
Industry Standards and Required Protocols
Professional standards for catheter care require comprehensive monitoring protocols and rapid response to infection signs. Facilities must have systems to ensure STAT laboratory orders are processed according to contracted timeframes, typically within four hours for urgent results.
The laboratory contract in this case specifically stated that STAT services would be provided 24 hours per day, 365 days per year, with results reported within four hours and facility notification within 30 minutes of any delays. However, the facility lacked policies specifying minimum contact attempts or follow-up procedures when laboratory services experience delays.
Standard protocols also require continuous assessment of catheterized patients, particularly those with histories of recurrent infections. Weekend gaps in monitoring represent a significant deviation from accepted care standards, especially for residents showing active signs of infection.
Additional Issues Identified
Inspectors documented several other concerning practices including inadequate pain management protocols, missing physician notifications for worsening symptoms, and lack of comprehensive policies for laboratory service coordination. The facility also failed to maintain proper communication logs in their physician notification system, with important documentation being discarded without retention.
The inspection findings highlight systemic issues with emergency response protocols, laboratory coordination, and clinical oversight that extended beyond individual care decisions to encompass facility-wide safety procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Meadows from 2024-08-01 including all violations, facility responses, and corrective action plans.
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