OCOEE, FL - A federal complaint investigation found that a stroke patient at Solaris Healthcare Lake Bennet developed life-threatening septic shock after nursing staff failed to carry out a physician-ordered urine test, falsely recorded it as completed, and never notified the doctor — a chain of failures that left the resident on a ventilator in the intensive care unit for more than two weeks.
The Centers for Medicare & Medicaid Services (CMS) survey, completed May 17, 2025, resulted in immediate jeopardy citations under both F-Tag 600 (free from abuse and neglect) and F-Tag 684 (quality of care), the most serious deficiency level federal regulators can assign to a nursing home.
Physician's Order Entered — But Never Carried Out
The resident, a male stroke survivor with multiple complex medical conditions including paralysis, diabetes with nerve damage, difficulty swallowing, and cognitive impairment, was admitted to the Ocoee facility from an acute care hospital. He was dependent on staff for all activities of daily living and used a wheelchair.
Shortly after admission, nursing staff observed blood-tinged urine in the resident's incontinence brief. A licensed practical nurse obtained a physician's order for a urinalysis with culture and sensitivity (UA/CS) — a standard diagnostic test used to identify urinary tract infections and determine which antibiotics would be effective against the specific bacteria involved.
The order was entered into the facility's computer system during the overnight shift. According to the inspection report, the nurse who entered the order could not recall whether she printed a copy and placed it in the collection tracking binder at the nurses' station, as facility protocol required.
A Critical Test Falsely Documented as Complete
When the next overnight nurse, identified in the report as LPN A, came on shift, the pending UA/CS order was waiting. During her interview with investigators, LPN A acknowledged she attempted to collect a urine specimen twice and was unable to do so. She described the resident's response as a refusal.
What happened next set off the chain of events that nearly cost the resident his life. Rather than documenting the failed collection attempts in a progress note, contacting the physician for alternative instructions, or notifying nursing management, LPN A signed the order as completed on the Medication Administration Record. She told investigators she marked it as "refused" but the MAR showed it as completed — and she wrote no progress note explaining what actually occurred.
Once signed off as complete, the order dropped out of the facility's tracking system. No one followed up on the missing lab results. The physician, the unit manager, and the physician assistant who regularly reviewed orders and results at the facility all failed to catch the discrepancy.
LPN A told investigators that obtaining urine specimens during overnight hours was difficult because residents were sleeping, but confirmed she understood the protocol: when a resident refuses a procedure, the nurse should promptly notify both the Director of Nursing and the physician.
Condition Deteriorates Into a Medical Emergency
Approximately one week after the urine test should have been performed, the resident developed a fever of 100.2 degrees Fahrenheit. A nurse administered Tylenol per standing orders and contacted the physician assistant, who ordered routine laboratory work. That afternoon, the resident reported hip pain and was given Tramadol, an opioid pain medication.
Within roughly 90 minutes of receiving the Tramadol, the resident's condition changed dramatically. When family members arrived to visit, they found him slow to respond to verbal commands and touch, with dilated pupils and sweaty, clammy skin. His blood pressure had dropped to 85/50 mmHg — dangerously low and consistent with the body's inability to maintain adequate circulation.
The resident's daughter, a paramedic by training, recognized the signs of potential septic shock and insisted the facility call 911 immediately. The PA initially ordered STAT labs and IV fluids, but the family was not willing to wait. "The family was very concerned he needed emergent care and insisted he be sent to the ER immediately," the inspection report documented.
The resident's wife later told investigators: "I believed my husband would have died had we not been there and insisted he go immediately."
Life-Saving Measures in the Emergency Room
During transport, EMS personnel had to use a bag-valve mask to manually maintain the resident's breathing — a device used when a patient can no longer breathe adequately on their own. Upon arrival at the emergency room at approximately 4:30 PM, medical staff immediately implemented life-sustaining interventions.
The resident required:
- Endotracheal intubation (insertion of a breathing tube) - Mechanical ventilation (breathing by machine) - Central venous catheter insertion for IV medications to stabilize blood pressure - Urinary tract irrigation due to severe sepsis - IV antibiotics for UTI and septicemia (blood infection)
He was transferred to the ICU, where the attending physician documented: "Upon my evaluation, this patient has high probability of imminent, life-threatening, or organ-threatening deterioration and I provided life/organ saving interventions."
The resident's hospital diagnoses told the full story of what an untreated urinary tract infection had become: critical hypotension, acute toxic encephalopathy (brain dysfunction), acute respiratory failure with low blood oxygen, acute tubular necrosis (severe kidney cell damage), and septic shock from UTI.
He remained hospitalized for more than two weeks before being discharged to a different long-term care facility for continued recovery. He never returned to Solaris Healthcare Lake Bennet.
How an Untreated UTI Becomes Septic Shock
A urinary tract infection that is identified early can typically be treated with a course of oral antibiotics. When left undiagnosed and untreated, however, the bacteria can multiply and enter the bloodstream — a condition called septicemia. The body's immune response to this overwhelming infection can trigger sepsis, which causes widespread inflammation, blood clotting in small vessels, and damage to organs throughout the body.
Septic shock represents the most dangerous stage of this progression. Blood pressure drops to critically low levels, organs begin to fail, and without immediate emergency intervention, the condition is frequently fatal. Elderly patients with multiple chronic conditions — such as this resident's diabetes, history of stroke, and compromised immune function — face significantly higher mortality risk.
The resident's attending physician confirmed what federal investigators had already concluded. "Undetected UTI can lead to sepsis; in this case that is what happened," he told surveyors. The facility's own Medical Director echoed this assessment, stating that "unidentified UTI can lead to sepsis."
Facility's Own Investigation Confirmed Neglect — But Was Never Reported
The facility did not learn of the missed test until weeks later, when the resident's wife called requesting the UA/CS results. The Director of Nursing reviewed the medical records and discovered the test was never performed despite being signed off as completed.
The facility conducted an internal investigation and confirmed LPN A had documented the test as done when it was not. The facility's own Risk Manager acknowledged during interview with investigators that the situation met the facility's definition of neglect, stating: "Neglect is not providing goods and services; goods and services did not occur because they did not provide the UA."
Despite this determination, the facility did not report the incident to the state agency as required until surveyors raised the issue during the May 2025 complaint investigation. The Nursing Home Administrator submitted the required Facility Reported Incident only after it was brought to their attention during the survey.
The DON told investigators she believed the resident was hospitalized for "something infection based" and acknowledged the facility never requested hospital records to determine whether the failure to complete the urine test contributed to the hospitalization.
Additional Deficiency: Missing Care Plan for Catheter Patient
Investigators also cited the facility under F-Tag 656 for failing to develop a comprehensive care plan for a separate resident who had an indwelling urinary catheter. Despite the MDS assessment triggering inclusion of catheter care in the care plan, it was omitted. The MDS Coordinator acknowledged the error, telling surveyors: "It was overlooked and not placed in the care plan."
What Should Have Happened
Standard nursing protocols require clear steps when a physician-ordered lab test cannot be completed. The nurse should document the reason in a progress note, notify the physician so alternative collection methods or treatment approaches can be considered, and inform nursing management. The physician can then decide whether to attempt collection by different means, prescribe empiric antibiotics based on clinical symptoms, or take other appropriate action.
In this case, multiple safeguards failed simultaneously. The collecting nurse did not document or report the failed collection. The order tracking system allowed a falsely completed order to disappear from follow-up. Unit managers responsible for checking lab collection binders did not catch the gap. And providers who reviewed the resident's records did not identify the absence of results.
The resident's wife reflected on the lasting impact during her interview with investigators: "Looking back, he had no energy and would fall back like a ragdoll; no wonder he had no energy; he wasn't like that before; even now, he has gone down a lot."
Solaris Healthcare Lake Bennet, located at 1091 Kelton Ave in Ocoee, Florida, was required to submit a plan of correction addressing the immediate jeopardy findings. The full inspection report with the facility's corrective action plan is available through the CMS Care Compare database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Solaris Healthcare Lake Bennet from 2025-05-17 including all violations, facility responses, and corrective action plans.
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