OCOEE, FL - Federal inspectors found immediate jeopardy violations at Lake Bennet Center for Rehabilitation & Healing after a critical laboratory test failure led to a resident's life-threatening septic shock and emergency hospitalization.
The May 17, 2025 complaint inspection revealed that nursing staff falsely documented completion of a physician-ordered urinalysis while a stroke patient with diabetes developed an undetected urinary tract infection that progressed to sepsis.
Critical Test Never Performed Despite Documentation
A male resident with multiple complex medical conditions including stroke-related paralysis, diabetes, and swallowing difficulties had blood-tinged urine observed by nursing staff. The attending physician ordered a urinalysis and urine culture test to identify any infection.
Licensed Practical Nurse A signed documentation indicating the test was completed on the required date. However, the test was never actually performed. The nurse later admitted to facility administrators that she attempted to collect the specimen twice but was unsuccessful, yet failed to notify the physician or document the refusal.
"I learned my lesson that when I go do a procedure and they refuse, don't wait until the end of the shift; notify the DON and the doctor," the nurse told investigators.
The resident's wife discovered the test was never done when she called requesting results weeks later. "They never did a urinalysis, they just didn't do it," she told inspectors. "We came in and basically had to find him catatonic before they did something."
Medical Emergency and Life-Saving Interventions
Without proper diagnostic testing, the resident's condition deteriorated rapidly. On the day of hospitalization, nursing staff administered pain medication for the resident's complaints. Within hours, family members visiting found him unresponsive with dilated pupils and profuse sweating.
The resident's vital signs showed critical hypotension with blood pressure readings of 85/50 mmHg. His daughter, who worked as a paramedic, recognized signs of potential septic shock and insisted on immediate emergency room transport.
Emergency Medical Services personnel had to manually maintain the resident's breathing using a bag-valve mask during transport. Upon hospital arrival, life-sustaining interventions were immediately implemented including:
- Endotracheal intubation for respiratory support - Mechanical ventilation - Central IV line placement for medication administration - Genitourinary tract irrigation for severe sepsis
Hospital Course and Complications
The resident required over two weeks of intensive care unit treatment for multiple life-threatening complications. Hospital physicians documented "high probability of imminent, life-threatening, or organ-threatening deterioration" and provided emergency interventions to prevent death.
The resident's final hospital diagnoses included critical hypotension, acute toxic brain dysfunction, respiratory failure requiring mechanical ventilation, severe kidney cell damage from oxygen deprivation, and septic shock from the urinary tract infection.
Septic shock occurs when the body's response to infection causes dangerous drops in blood pressure and organ dysfunction. Without prompt identification and treatment of the underlying infection, sepsis can rapidly progress to multiple organ failure and death.
Systemic Failures in Laboratory Management
The inspection revealed multiple breakdowns in the facility's laboratory testing procedures. Nursing staff were responsible for collecting specimens during night shifts when residents were typically sleeping, creating challenges for obtaining samples from uncooperative patients.
The facility's policy required designated nurses to review laboratory tracking logs daily and follow up on discrepancies. However, this oversight system failed to identify that the urinalysis order had been falsely marked as completed.
Unit Managers were responsible for checking specimen collection tracking, but the missing test was not detected until the family specifically requested results weeks after the order was placed.
Medical Standards for Infection Detection
Urinalysis serves as a crucial diagnostic tool for detecting urinary tract infections, particularly in vulnerable populations like nursing home residents. The test examines urine for bacteria, blood cells, and other indicators of infection or kidney dysfunction.
When blood appears in urine, immediate diagnostic testing is essential to determine the underlying cause, which may include infection, kidney stones, or other serious conditions requiring specific treatment approaches.
For residents with multiple medical conditions like diabetes and stroke, prompt identification of infections is critical because these individuals face higher risks of developing sepsis and related complications.
Provider Expectations and Communication Requirements
The attending physician and facility Medical Director both confirmed expectations that laboratory orders would be completed as requested and that medical providers would be notified if specimens could not be obtained.
"Undetected UTI can lead to sepsis; in this case that is what happened," the attending physician told investigators, emphasizing the direct connection between the testing failure and the resident's medical emergency.
The Physician Assistant who provided care during the crisis explained that urinalysis orders should be processed the same day and sent to laboratories, with nursing staff expected to notify providers when tests cannot be completed for alternative decision-making.
Family Impact and Recovery Challenges
The resident's wife described the traumatic experience of finding her husband in a catatonic state during what was supposed to be a routine visit. The family had previously expressed concerns about possible infection symptoms but were told by nursing staff that the resident just needed to "sleep it off."
Following the emergency hospitalization and intensive care treatment, the resident required transfer to another long-term care facility for continued recovery and rehabilitation services, representing a significant disruption to his care continuity.
The incident resulted in substantial medical complications that required extended hospital treatment and likely affected the resident's long-term health outcomes and functional abilities.
Regulatory Violations and Immediate Jeopardy
Federal inspectors cited the facility for immediate jeopardy violations related to comprehensive care planning and failure to ensure ordered treatments were provided. The violations affected few residents but posed serious risks to health and safety.
The facility's assessment claimed to provide early identification of medical problems and person-centered care for genitourinary system disorders, capabilities that were clearly not demonstrated in this case.
Current facility policies require prompt notification of medical providers and resident representatives regarding condition changes and treatment refusals, procedures that were not followed according to the inspection findings.
The case demonstrates how seemingly routine administrative failures in healthcare settings can escalate to life-threatening medical emergencies when proper oversight and communication systems break down.
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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