AVON, IN - Federal inspectors cited Countryside Meadows nursing home after discovering staff failed to notify a resident's family of a critical urinary tract infection that ultimately led to the resident's death from urosepsis and acute kidney injury.
The facility received the citation following a complaint investigation completed on August 1, 2024. Inspectors found that Resident F's family was only contacted on May 31, 2024 - the day he died - despite his condition having deteriorated significantly over the previous weekend.
Critical Communication Breakdown
According to the inspection report, the facility called Resident F's family member on May 31 only to confirm his Do-Not-Resuscitate orders because he had developed an infection and experienced a change in condition. During this call, staff asked if the family wanted the resident sent to the hospital.
The family member told inspectors they "had been unaware that Resident F was being treated for an infection and that his condition had worsened so severely." They noted that while the resident had a history of infections that "could get bad fast," they were never informed this infection had begun.
When the family member arrived at the facility, an ambulance was already at the door. Upon reaching the resident's room, emergency medical services and the facility nurse indicated there was nothing more they could do. The resident took his final breaths moments after his family entered the room.
Medical Context and Progression
Resident F was a long-term care resident with multiple serious conditions including a history of cerebral infarction that resulted in left-side weakness, Alzheimer's disease, and neurogenic bladder dysfunction requiring a surgically placed suprapubic catheter for urinary drainage.
Medical records show that a STAT (immediate) care plan was initiated on May 24 at 3:13 p.m., indicating the severity of his condition was recognized by clinical staff. However, documentation reveals that family notification was not completed until May 31 at 12:22 p.m. - seven days later and on the day of his death.
The inspection report indicates Resident F's condition "continued to decline over the weekend of May 25th-26th with critical lab results and acute SIRS related bruising." SIRS, or systemic inflammatory response syndrome, represents the body's severe response to infection and can quickly progress to life-threatening complications.
Understanding Urosepsis and Its Dangers
Urinary tract infections in nursing home residents can rapidly progress from localized bladder infections to urosepsis - a life-threatening condition where bacteria from the urinary system enter the bloodstream. This progression is particularly dangerous for residents with compromised immune systems or underlying health conditions.
Acute kidney injury, as documented in this case, occurs when the kidneys suddenly cannot filter waste from the blood. In the context of urosepsis, this represents a critical complication that requires immediate medical intervention and hospitalization.
Residents with suprapubic catheters face increased infection risks due to the direct connection between the external environment and the urinary system. Regular monitoring and prompt treatment of any signs of infection are essential for preventing serious complications.
Regulatory Requirements for Family Notification
Federal regulations require nursing homes to immediately notify residents' families or representatives of significant changes in condition, injuries, or situations that could affect the resident's health or well-being. This notification must occur as soon as possible, not days after the change is recognized.
The regulation exists specifically to ensure families can participate in care decisions and be present during critical moments. Prompt notification allows families to advocate for their loved ones, seek second opinions, or simply provide emotional support during difficult times.
Facility's Care Planning Documentation
The inspection revealed that Resident F had a comprehensive care plan dating back to 2012 when he entered long-term care. His Physician's Orders for Scope of Treatment (POST) form from 2020 specified that while he was designated as Do-Not-Resuscitate for cardiac arrest situations, he wanted "full interventions including life support measures" for other medical conditions, including hospital transfer when indicated.
The care plan specifically included interventions to "encourage family/friends to stay involved in resident care," making the communication failure more significant given the facility's documented awareness of family involvement goals.
Impact on Families and Trust
The delayed notification not only prevented the family from participating in end-of-life decisions but also created emotional trauma. The family member described being "shocked and in denial that this had happened so quickly" and expressed confusion about why they weren't informed when the infection began.
This case highlights the critical importance of transparent, timely communication between nursing homes and families, particularly for residents with complex medical conditions who may experience rapid deterioration.
The Centers for Medicare & Medicaid Services classified this violation as causing "minimal harm or potential for actual harm" affecting "few" residents, though the emotional impact on the affected family was significant.
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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