ARCADIA, CA - A state inspection at Arcadia Care Center revealed that facility staff failed to carry out physician-ordered laboratory testing and discontinued necessary antibiotic treatment for a resident with a drug-resistant urinary tract infection, resulting in deteriorating mental status and emergency hospitalization.
Treatment Discontinued Due to Cost Concerns
A resident admitted to Arcadia Care Center on January 7, 2025, arrived with documented diagnoses including a urinary tract infection and carrier status of Carbapenem-resistant Enterobacterales (CRE), a group of bacteria highly resistant to multiple antibiotics. The resident had been discharged from a hospital with orders to continue intravenous administration of ceftazidime-avibactam, a specialized antibiotic specifically indicated for resistant bacterial infections.
According to hospital emergency department records from the resident's subsequent readmission, the facility discontinued the prescribed antibiotic regimen due to the high cost of the medication. Hospital documentation noted that "because of the high cost of the antibiotics, [the facility] had not given the antibiotics to [the resident] since [the resident] was discharged from [the hospital]."
The facility's medical director confirmed during the investigation that the antibiotic was discontinued on January 8, 2025, one day after admission. The resident received no antibiotic treatment or alternative therapy for the resistant urinary tract infection for five consecutive days, from January 8 through January 12, 2025.
Physician-Ordered Testing Not Performed
When the treating physician discontinued the expensive antibiotic on January 8, the physician simultaneously ordered urinalysis with culture and sensitivity testing to be collected on January 9. This testing was essential to identify whether alternative, less costly antibiotics might effectively treat the infection.
Investigation of the resident's medical records from January 8 through January 12 revealed no documentation that facility staff attempted to collect the urine sample as ordered. The admitting registered nurse confirmed during the inspection that there was no evidence the physician's order was carried out and stated that laboratory orders needed to be executed as soon as possible.
The medical director explained that the follow-up urinalysis was ordered specifically to determine if another antibiotic would be effective against the infection. Without this critical diagnostic information, clinical staff had no basis for prescribing alternative treatment, leaving the resident without any antimicrobial therapy during this period.
Medical Consequences of Treatment Gaps
Urinary tract infections caused by resistant bacteria require continuous, appropriate antibiotic therapy to prevent progression to more severe systemic infections. When antibiotic treatment is interrupted, bacterial populations can proliferate rapidly, potentially spreading from the urinary tract to the bloodstream. The medical director noted that this resident had been admitted for treatment of Pseudomonas-resistant bacteremia, indicating bacteria had already entered the bloodstream.
Altered mental status, which developed in this case, represents a serious complication frequently associated with untreated or undertreated infections in elderly populations. Changes in cognitive function often signal that an infection has progressed or that systemic inflammatory responses are affecting brain function. According to the medical director, altered mental status is a symptom of infection and indicated the resident's condition had deteriorated.
On January 12, facility staff ordered urinalysis due to the resident's confusion. By January 13, the resident's mental status had declined sufficiently to warrant emergency transfer to the hospital. Emergency medical services transported the resident at 11:27 a.m., with hospital triage documenting the resident arrived with increased confusion that had started the previous day, elevated white blood cell counts indicating active infection, and confirmed urinary tract infection.
Standard Protocols Not Followed
According to the facility's own policy titled "Lab and Diagnostic Test Results - Clinical Protocol," physicians identify and order diagnostic testing based on residents' needs, and nursing staff are responsible for processing test requisitions and arranging for tests to be completed. The policy specifies that nurses should determine whether ordered tests were performed.
The Director of Nursing acknowledged during the investigation that when the physician ordered the urine sample to be collected on January 9, it should have been obtained that same day to prevent delays in care. The director confirmed the resident experienced a delay in care specifically because the urinalysis was not carried out as ordered, which prevented the resident from receiving any treatment for the infection.
The medical director stated that failure to obtain the diagnostic testing as soon as possible prevented appropriate treatment and caused a delay in care that resulted in the resident's rehospitalization. The admitting nurse characterized the situation as a "delay in care" and confirmed the resident "did not receive any antibiotics or other treatment" for the urinary tract infection during the five-day period.
Emergency Hospitalization and Resumed Treatment
Hospital emergency department records documented that upon arrival, the resident received a dose of the originally prescribed antibiotic, ceftazidime-avibactam. The hospital physician coordinated with the facility to ensure the resident would receive the necessary antibiotics upon return. The resident was readmitted to the facility on January 13, 2025, with orders to continue ceftazidime-avibactam through January 16.
The licensed vocational nurse interviewed during the inspection stated that "the resident's care was not up to par" and confirmed the resident did not receive the needed antibiotics to treat the infection during the critical period.
Additional Issues Identified
The inspection also documented that the facility failed to follow its established protocols for physician-ordered diagnostic testing and failed to provide timely notification to the physician regarding the inability to administer prescribed medications due to cost concerns.
This case demonstrates the potential consequences when administrative or financial considerations interfere with medically necessary care, particularly for residents with infections caused by drug-resistant organisms that require specialized treatment protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Health Care Center from 2025-01-30 including all violations, facility responses, and corrective action plans.
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