HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to follow-up on lab results and failed to provide timely treatment for a positive urine culture for 1 discharged patient (Patient #1) presenting to the Emergency Department (ED) of 8 ED patients reviewed.

The findings include:

Review of the facility's policy "Callback and Documentation in the ED" revised 1/2022 showed "...To provide guidelines for notification of Emergency Department (ED) patients of finalized test results reported after they have been discharged from the ED that require a change in treatment, and for documentation of notification. Finalized lab and radiology test results reported after a patient's discharge from the ED will be routinely reconciled. The ED physician or Mid-Level Provider (MLP) on duty will review all applicable results, the treatment provided and adjust treatment as appropriate. Facility designated staff will contact the patient with further instructions as indicated by the provider. This notification will be documented in the patient's medical record...Lab results that are reported after a patient's discharge from the ED will be routinely reconciled by facility designated staff. Facility designated staff will contact the patient with further instructions as indicated by the provider...If lab or radiology results are called to ED by Lab/Radiology Personnel and identified as a critical result, the ED staff will follow facility policy for communication critical test/critical results...Call back Procedure...The staff will document all attempts of patient notification in the patient medical record...If unable to contact the patient by telephone, a certified letter will be sent to the patient. If a certified letter is sent to the patient, the results may also be faxed to the PCP [Primary Care Physician], Nursing Home or other receiving facility as indicated by the ED provider. This will be documented in the patient medical record..."

Medical record review of an ED triage (clinical assessment of patient's presenting signs and symptoms) note showed Patient #1 arrived by ambulance to the ED on 10/6/2022 with complaints of weakness, dizziness, all over body discomfort, and shortness of breath. The patient was triaged as a level 3 (urgent) on the Emergency Severity Index (ESI) system (a 5 level system used to categorize ED patients).

Medical record review of an ED provider note showed Patient #1 was evaluated by a Physician's Assistant (PA) on 10/6/2022 at 3:34 PM. The patient reported "...she just does not feel good and feels weak..." Patient #1's past medical history included Kidney Stones and Kidney Infection.

Medical record review of Patient #1's (voided/clean catch) urinalysis results for 10/6/2022 at 3:42 PM showed the following:
Color - Light-Yellow (reference range light-yellow)
Clarity - Clear (reference range-clear)
Specific Gravity - 1.035 (reference range 1.005-1.030)
PH - 5.5 (reference range 4.5-8.0)
Glucose - 4+ (reference range negative)
Protein - Negative (reference range negative-trace)
Bilirubin - Negative (reference range negative)
Urobilinogen - Normal (reference range normal)
Blood - Negative (reference range negative-trace)
Ketones - Negative (reference range negative)
Leukocyte - Negative (reference range <26)
RBC - 0-5 (reference range 0-5)
WBC - 6-10 (reference range 0-5)
Squamous Epithelial - 21-40 (reference 0-20)
Mucous - Trace (reference range trace-few)
Hyaline Cast - 0-4 (reference range 0-10)
The results reflexed for a urine culture to be performed.

Medical record review of an ED provider (PA) note dated 10/6/2022 at 5:38 PM showed Patient #1's urinalysis was "...grossly unremarkable. Urine reflex culture will be sent off..."

Medical record review of an ED visit summary showed Patient #1's disposition was changed to discharged on 10/6/2022 at 6:58 PM and the patient was discharged at 7:05 PM. Patient #1's diagnoses included Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, Shortness of Breath, Difficulty in Walking, and Weakness.

Medical record review of a urine (voided/clean catch) culture collected on 10/6/2022 and resulted (final result) on 10/8/2022 showed a bacteria count greater than 100,000 (reference range 0-10,000 colonies of bacteria/milliliter).
"...Testing to guide therapy is not routinely needed. Therapeutic option: Penicillin [antibiotic] is the drug of choice. Penicillin with or without an aminoglycoside [a substance that works against many types of bacteria]; ceftriaxone [antibiotic], or cefotaxime [antibiotic] may be used instead of penicillin; vancomycin [antibiotic] is used for penicillin allergic patients..." The urine culture was positive for ...STREP AGALACTIAE GROUP B...[Group B Strep bacteria]..."

Medical record review of an ED callback log showed Patient #1 was listed on the log on 10/8/2022 at 11:49 AM. The electronic system automatically listed the patient due to the patient's positive urine culture results. The call status was documented as completed on 10/10/2022 (2 days after the patient was placed on the callback log) at 12:15 PM. There was no documentation to show Patient #1 had been notified of the positive urine culture results or that antibiotics had been ordered for the patient.

During an interview on 11/28/2022 at 2:30 PM, in the conference room, the Chief Nursing Officer (CNO) reviewed the ED callback log and confirmed Patient #1 was listed on the log on 10/8/2022 due to a positive urine culture. The CNO stated it appeared the Nurse Practitioner had reviewed the results on 10/10/2022 but there were no callback instructions to notify the patient of the positive urine culture results nor an order for an antibiotic.

During a telephone interview on 11/28/2022 at 5:00 PM, Patient #1 stated she discovered the positive urine culture results in her patient portal (a secure online website that gives patients access to personal health information). Patient #1 stated no one from the facility contacted her regarding the positive urine culture results nor did the facility provide a prescription for an antibiotic. Patient #1 contacted her family physician who sent a prescription for an antibiotic to the patient's pharmacy.

During a telephone interview on 11/29/2022 at 1:55 PM, Physician Assistant (PA) #1 stated he ordered a urinalysis for Patient #1 and confirmed a urine culture was performed on the urine specimen. PA #1 confirmed the urine culture was positive for Group B Strep. PA #1 stated Penicillin was the drug of choice to treat Group B Strep and he would have ordered an antibiotic had he been the one to review the urine culture results.

During an interview on 11/29/2022 at 3:25 PM, in the ED, Nurse Practitioner (NP) #1 stated the physician or midlevel (PA or NP) provider checked the callback log every day. If a patient has a positive culture the provider leaves an electronic note/instructions in the computer and a nurse calls the patient to notify them of the results, treatment and/or change in treatment. NP #1 reviewed Patient #1's urine culture results during the interview, confirmed he had reviewed the results on 10/10/2022, and confirmed the patient's urine culture was positive for Group B Strep. NP #1 stated he did not see the treatment recommendations for an antibiotic in the details of the report or he would have ordered an antibiotic for the patient. NP #1 confirmed he did not order an antibiotic for Patient #1.