LOS ANGELES, CA - Federal inspectors cited Culver West Health Center after discovering staff delayed antibiotic treatment for a dialysis patient experiencing a urinary tract infection, creating potential for life-threatening complications.
Nine-Day Delay in Critical Antibiotic Administration
The May 2025 inspection revealed that Resident 29, who was dependent on renal dialysis and required assistance with daily activities, reported painful urination and difficulty voiding on April 17, 2025. The facility's physician ordered a urinalysis with culture and sensitivity testing that same evening at 11:08 PM.
However, the urine sample was not collected until April 19, 2025 - a delay that extended the timeline for diagnosis and treatment. Laboratory results on April 21, 2025 showed significant indicators of infection: white blood cell counts exceeded 50 per high power field (normal range is 0-2), protein levels measured 3+ mg/dL, and the sample contained bacteria and moderate mucus while appearing cloudy.
Despite these abnormal results indicating an active infection, nursing staff failed to initiate a change in condition notification or contact the physician immediately. The culture and sensitivity results arrived on April 24, 2025, confirming the need for antibiotic treatment with Ertapenem 1 gram intramuscularly once daily for seven days.
Compounding Delays and Communication Failures
The first dose of the prescribed antibiotic was not administered until April 28, 2025 - four days after the order was received and nine days after the initial urine sample collection. During this period, multiple breakdowns in communication and protocol occurred.
On April 26, 2025, the facility pharmacist questioned whether to proceed with the Ertapenem order due to the resident's documented penicillin allergy. While the physician confirmed the order should continue, this represented another 24-hour delay in treatment initiation.
The following day, April 27, 2025, nursing notes indicated the medication was not administered because staff believed it was ordered as an intravenous medication rather than intramuscular injection. Medical records contained no evidence that staff contacted the physician to clarify the order or reported the delay in administration.
Medical Significance of Treatment Delays
Urinary tract infections in dialysis patients represent a particularly serious medical concern. Dialysis patients face compromised immune function and altered fluid balance, making them more vulnerable to rapid progression of infections.
When bacteria multiply unchecked in the urinary system, the infection can spread to the bloodstream, causing bacteremia. Left untreated, this progression leads to sepsis - a systemic inflammatory response that damages multiple organ systems simultaneously. In dialysis patients, sepsis carries mortality rates ranging from 20-50 percent depending on severity and timing of intervention.
The laboratory findings in this case indicated active bacterial infection with significant inflammatory response. White blood cell counts exceeding 50 per high power field represent severe immune system activation. The presence of protein, bacteria, and mucus in cloudy urine confirms substantial tissue inflammation and bacterial colonization.
Each day of delayed antibiotic treatment allows bacterial populations to double multiple times, increasing the bacterial load and inflammation throughout the urinary system. For a resident already experiencing painful urination and voiding difficulty, this delay prolonged discomfort and increased infection severity.
Resident's Perspective on Care Delays
During the April 30, 2025 inspection interview, Resident 29 confirmed experiencing pain and difficulty with urination that began approximately two weeks before antibiotic treatment started. The resident reported notifying facility staff about these symptoms when they began.
"The antibiotics were started three days ago," Resident 29 told inspectors. "There was a delay in the process and felt like the antibiotic should have been started/administered to me sooner than the facility did."
This statement confirms the resident experienced prolonged discomfort while waiting for treatment, recognizing that the facility's response time was inadequate for the severity of symptoms.
Facility Protocol Violations
The facility's own policies establish clear standards for responding to infection symptoms and abnormal laboratory results. The Change in a Resident's Condition or Status policy requires prompt notification of the attending physician when significant changes occur that will not resolve without intervention.
The Abnormal Laboratory Value Reporting and Documentation Guideline explicitly states: "Notify physician of the results as soon as the result is received." This policy exists specifically to ensure proper interventions can be implemented without delay.
In interviews with inspectors, facility leadership acknowledged multiple protocol failures. The Registered Nurse Supervisor stated that urinalysis orders for symptomatic residents should be processed as STAT (immediate) orders, with samples collected within 6-8 hours. The Director of Nursing confirmed abnormal laboratory results must be communicated to the physician immediately upon receipt to prevent delays in care and further discomfort.
The facility's medical doctor explained that culture and sensitivity orders need sample collection the same day or next day after ordering, and abnormal results should be reported to physicians 2-3 hours after receipt. The physician noted that intramuscular antibiotic administration is specifically chosen for serious infections requiring immediate systemic treatment.
Additional Infection Control Concerns
Inspectors also documented infection prevention failures involving Resident 71, who had a neurogenic bladder requiring an indwelling urinary catheter. During observation on April 29, 2025, nursing staff noted the catheter drainage bag lacked any label indicating when it was last changed.
The Licensed Vocational Nurse acknowledged that drainage bags should be changed monthly or as needed, and that proper labeling is essential to prevent obstruction, infection, potential misdiagnosis, and other complications. However, the Treatment Administration Record for April 2025 contained no documentation of when the catheter bag was last changed.
Without dated labels on drainage equipment, nursing staff cannot determine when routine changes are due or identify equipment that may be harboring bacterial growth. Urinary catheter systems represent direct pathways for bacteria to enter the bladder, making proper maintenance and timely equipment changes essential for infection prevention.
Healthcare Standards for Urinary Infection Management
Established clinical guidelines emphasize the importance of rapid treatment initiation for urinary tract infections, particularly in vulnerable populations. The Centers for Disease Control and Prevention recommends obtaining urine cultures before starting antibiotics, but not delaying treatment when clinical symptoms indicate active infection.
For dialysis patients and those with indwelling catheters, the risk-benefit calculation strongly favors early intervention. These populations face elevated risks for ascending infections that spread to the kidneys (pyelonephritis) and bloodstream infections that can trigger septic shock.
Antibiotic stewardship principles support obtaining culture results to guide appropriate drug selection, but the nine-day delay between symptom onset and treatment initiation in this case exceeded any reasonable timeframe for diagnostic workup. Standard practice calls for treatment initiation within 24-48 hours of positive culture results, with immediate empiric treatment for severely symptomatic patients.
Facility Response and Regulatory Action
The inspection resulted in citations under F690 (Urinary Incontinence/Catheter Care) and F760 (Medication Errors), both rated at minimal harm or potential for actual harm affecting few residents. Federal surveyors determined the facility failed to provide infection prevention services and failed to ensure residents were free from significant medication errors.
The inspection report notes this deficient practice "had the potential to result in hospitalization and/or death for Resident 29." This assessment reflects the serious medical consequences that can result from untreated urinary infections in dialysis patients.
Implications for Resident Safety
This case illustrates how multiple system failures - delayed specimen collection, failure to report abnormal results, confusion about medication administration routes, and inadequate physician communication - can compound to create dangerous gaps in medical care.
For families evaluating nursing home quality, this inspection reveals concerning patterns in clinical decision-making and care coordination. The facility's own staff acknowledged that protocols exist to prevent these exact scenarios, yet failed to follow established procedures when a resident presented with infection symptoms.
The complete inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare database. Families can access detailed information about Culver West Health Center's inspection history, staffing levels, and quality measures to make informed decisions about care options.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Culver West Health Center from 2025-05-02 including all violations, facility responses, and corrective action plans.
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