HospitalInspections.org

Based on medical record review and interview, the physician failed to
treat Patient Identifier (PI) # 1's urinary tract infection prior to discharge from the Emergency Department (ED) on 3/13/15 and failed to prescribe an antibiotic until 3/20/15, eight days after PI # 1 presented to the ED. There is no policy and procedure related to treatment of an infection identified post discharge from the ED. This affected PI # 1, one of ten sampled ED patients.


Findings include:

Patient Identifier (PI ) # 1 presented to the Emergency Department (ED) on 3/12/15 at 20:59. According to the ED Registration Data Sheet, "uncontrolled blood sugar, vomiting, moments of incoherence and suicidal" were documented as the reason for visit / symptoms.

A review of the Physical Examination documented by the ED Physician on 3/12/15 at 21:46 revealed no information about PI # 1's Genitourinary system. There is no description or documentation about the patient's Genitourinary system.

A urinalysis report dated 3/12/15 at 22:14 revealed large bacteria was present in PI # 1's urine. (Urinalysis, a test that evaluates a sample of urine to detect urinary tract infections, kidney disease, diabetes... www.mayoclinic.org/tests.../urinalysis/basics).

A urine specimen for culture and sensitivity was ordered by the ED Physician on 3/12/15 at 21:15. (A culture is a test to find and identify germs (usually bacteria) that may be causing a urinary tract infection...
www.webmd.com/a-to-z-guides/urine-culture). The culture was positive for Escherichia coli (E coli) on 3/16/15. (E coli is a type of bacteria commonly found in the gastrointestinal tract that can enter the urinary tract and cause infection, www.mayoclinic.org/diseases-conditions/urinary-tract-infection).

A review of the ED Nursing Notes dated 3/18/2015 at 05:32 revealed, "Urine culture positive for E coli. Pt. (patient) discharged home with no Rx (prescription) for antibiotic. ED Physician (last name) reviewed. Recommendation for Keflex (antibiotic)...DCN to contact patient with result and call in Rx for Keflex."

A review of the ED Nursing Notes dated 3/20/2015 at 08:14 revealed, "Patient's urine culture came back positive for e-coli; called in Rx to...pharmacy for Macrobid (antibiotic)..."

During an interview on 6/12/15 at 11:45 with Employee Identifier (EI) # 1, the Quality/Risk Manager stated he/she has been unable to locate a policy and procedure related to patient notification of a positive test result after discharge from the Emergency Department. "It is more of a practice."