The resident developed a UTI that went undiagnosed from September 4 through September 13 at Methodist Manor Retirement Community. During that time, the resident's chart contained no nursing progress notes and no vital signs for 10 consecutive days.
Staff B, a certified nurse aide, worked with the resident in the days leading up to hospitalization. The aide told federal inspectors that the resident had reported pain during cleaning and that her skin appeared pink. The aide also noticed the resident's urine had a stronger odor than normal.
When Staff B reported these symptoms to Staff D, the registered nurse, the RN's response was to "continue to do peri care and let her know if it got worse and to push fluids." No assessment was documented. No vital signs were taken.
The resident's chart shows a complete gap in nursing documentation from September 4 through September 10. No vital signs were recorded from September 3 through September 13.
A doctor apparently wanted to order urinalysis tests when confusion was the resident's only documented complaint, but the nurse did not want to order the tests.
On September 13 at 2:37 PM, a urinalysis finally revealed the resident had bacteria in her urine. That same day at 6:00 PM, the resident was started on antibiotics for the confirmed UTI.
Four days later, on September 17, Staff D received a performance improvement plan citing "performance concerns including communication with residents and families." The document stated expectations that "all interactions with resident and or resident families were respectful, timely and professional."
Staff D refused to sign the performance improvement plan and terminated her employment immediately.
The Director of Nursing acknowledged to inspectors that nurses should document changes in residents' conditions such as burning with urination or odorous urine. She said she had talked to several staff members, and none reported to her that the resident had symptoms before the UTI was discovered.
"With a change in condition, the DON said that she would expect a note and vital signs if applicable," inspectors wrote.
The nursing director said there were "conflicts between a nurse and the family that caused a breakdown in communications."
Methodist Manor's own policy requires clinical documentation and assessment when residents experience condition changes, defined as "alteration from normal status." Licensed nurses must complete head-to-toe assessments including full vital signs when residents' conditions change.
The policy requires nurses' notes describing problems, vital signs documentation, and records showing "consistent follow up."
None of this happened. The resident experienced burning urination and odorous urine for days while receiving only basic hygiene care. The registered nurse dismissed the aide's reports and refused diagnostic testing that could have identified the infection earlier.
The certified nurse aide who reported the symptoms provided the resident's incontinence care and observed the changes firsthand. Her reports to the RN were ignored.
Federal inspectors found the facility failed to ensure residents received proper assessment and treatment for changes in condition. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The registered nurse's departure came immediately after being presented with performance concerns about professional communication. The timing suggests the UTI care failures were part of broader performance issues that led to the employment termination.
Methodist Manor's policy clearly outlined requirements for documenting and following up on condition changes, but staff failed to follow these procedures. The 10-day gap in nursing notes and vital signs represented a complete breakdown in basic nursing documentation during the period when the resident was experiencing UTI symptoms.
The case illustrates how communication failures between nursing staff and families can compromise resident care. When the aide reported concerning symptoms, the RN's dismissive response delayed proper assessment and treatment of a condition that ultimately required antibiotic therapy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Methodist Manor Retirement Community from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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