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Based on record review and interview, the Medical Staff failed to review transferred medical record for a new patient to ensure diagnosis of Urinary Tract Infection and initial treatment with antibiotics at the transferring hospital was not missed so that needed treatment could be continued.

This failed practice resulted in the facility not continuing the antibiotics the patient had started in the emergency room to treat the Urinary Tract Infection (UTI) in a timely manner. Citing one (1) patient named in a complaint (Patient # 2).

Findings:

Review of complaint narrative for Patient # 2 revealed the following information:

She was taken on 7/5/2017 to an Acute Care Hospital Emergency Room (ER) for Psychiatric evaluation and medication stabilization.

While in the Emergency Room Patient # 2 was diagnosed with Urinary Tract Infection (UTI) and was treated with Intravenous Antibiotic and was also started on oral antibiotic.

On 9/7/2017 the patient was transferred from the ER to the Psychiatric Hospital for care.


During her stay at the Psychiatric Hospital her mother's antibiotic treatment was not continued.

The Complainant stated she spoke to a Physician via skype during the admission process and explained all her mother's history including the fact she had been treated in the ER with antibiotics for UTI.

The Complainant alleged her mother was not given antibiotics until day of discharge (7/18/2017) despite several complaints to the staff at the Psychiatric Hospital telling them her mother had UTI and was on antibiotics which should be continued but nothing was done.


Review of medical record for Patient # 2 from the Acute Care ER revealed the patient was a Seventy Seven(77) year old female taken to the Emergency Room (ER) on 7/5/2017 by her family with complaints of aggressive behavior and being forgetful which started days ago and was worsening.

She complains of "stinging" suprapubic and abdominal pain and hallucinations which was relieved by nothing. Family requesting a psychiatric evaluation.

Laboratory report for urine test dated 7/5/2017 revealed urine was positive for Nitrates, High level of Leukocyte Esterase, urine bacteria many (H).
Urine culture with Gram Negative Rods (Bacteria).

There was documentation the patient had frequent episodes of UTI. Clinical Impression was Primary: Depression and;

Secondary Impression: Hallucinations and UTI.

Review of Physician orders dated 7/5/2017 revealed an order for Ceftriaxone Sodium (antibiotic) I Gram Intravenous.(which was administered) and;

Nitrofurantoin Macrocrystals(oral antibiotics) 100 mg orally twice a day to start 7/6/2017 and stop on 7/13/2017.
The patient was given two doses of the oral antibiotics on 7/6/2017 in the ER.

Review of Medical Record for Patient # 2 at the Psychiatric Hospital revealed she was admitted to the hospital from Acute Care ER on 7/7/2017.

Review of admission nursing assessment notes dated 7/7/2017 revealed documentation that the patient was sleepy with mild confusion. There was no documentation of UTI and treatment with antibiotics.

Review of physicians notes dated 7/8/2017 through 7/15/2017 revealed no documentation that the patient had UTI. There was no order for antibacterial medication.

Review of Multidisciplinary notes dated 7/13/2017 revealed information from discharge planning that "the patient's daughter expressed concerns about the patient's UTI and the connection with the patient's psychosis. The patient's daughter was informed to contact nursing staff regarding medical information"


Review of Physicians notes for Patient # 2 dated 7/16/2017 revealed the following information:

"Follow up urine culture report done secondary to visual hallucination reported by family. Resident seen, no abdominal pain.

Staff reports she sleeps a lot. There was no aggression. Hospital UA (Urinalysis) done on 7/5/2017 was positive (+) for Nitrate.

Bacteriuria, Fungi urea, acute symptomatic. Will cover with Diflucan (Antifungal) 100 mg daily by mouth for 5 days and Levaquin (Antibacterial) 250 mg by mouth for 5 days". The medication was ordered on 7/16/2017 at 12:30 pm.

Review of Medication Administration Record (MAR) revealed the medication was not started until 7/17/2017 at 0900. Patient #2 was discharged from the hospital on 7/18/2018.

During an interview on 10/4/2017 at the facility at 9:45 am with Staff A 51 Nurse Practitioner she stated after reviewing the medical record for Patient # 2 she realized she did not do a thorough review of the ER record that was sent with the patient during her admission assessment, as a result the diagnosis of Urinary Tract Infection (UTI) and antibiotic therapy was missed.

She stated she did review the home medication record and that was where her medication treatment focus was. She stated the antibiotic therapy should have continued when the patient was admitted to the Psychiatric Hospital.

During an on 10/3/2017 at 1:20 pm at the facility Staff # E 55 Director of Nursing she stated the antibiotics should have started on the day it was ordered and staff would be in-serviced. She stated Staff will also be in-serviced on patient assessment and review of transferred medical information.