COCHRAN, GA- BRYANT HEALTH AND REHABILITATION CENTER

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

15650

Based on record review, staff interview, and review of the facility policy titled Lab Procedures and Other Services, the facility failed to obtain a urine analysis (UA) with Culture and Sensitivity timely as ordered by the physician for one of ten residents(R) (R5) reviewed.

Findings include:

A review of the facility policy titled Lab Procedures and Other Services, dated August 2021, revealed it was the standard of the facility to provide laboratory and diagnostic studies for all residents in compliance with Federal and State requirements. All tests will be completed as ordered, results obtained, and reported to the attending physician or Medical Director, and other members of the Interdisciplinary Team, as appropriate to assist in the management of the disease process. The General Guidelines section indicates the Licensed Nurse ensures lab is drawn/conducted in a reasonable time frame (unless stat (immediate) order).

A review of the Health Status Note dated 10/19/2023 at 3:22 pm, noted R5 with altered mental status and complaints of burning when urinating. The Nurse Practitioner (NP) was made aware and new orders noted for UA with Culture and Sensitivity.

The Health Status Note dated 10/19/2023 at 4:00 pm, documented an attempt to obtain a urine sample from the resident by in and out catheter was unsuccessful. Encouraged the resident to drink plenty of fluids and would pass on in report.

There was no further documentation that staff attempted to obtain the urine specimen until 10/23/2023. There was also no documentation that the staff notified the physician of the failed attempt to obtain the UA on 10/19/2023.

The Health Status Note dated 10/23/2023 at 11:26 am, indicated the Director of Nursing (DON) obtained the UA and it was taken to the local hospital for the UA and Culture with Sensitivity.

According to the 10/24/2023 at 12:32 am Health Status Note, the resident was started on Bactrim DS (an antibiotic) as ordered for a urinary tract infection (UTI).

On 10/26/2023 the resident was assessed by the NP for a follow-up related to the UTI who noted the resident was on Bactrim for UTI with final culture possible colonization. The NP noted to complete Bactrim and push fluids.

The 10/27/2023 at 8:35 am a Situation, Background, Assessment, Recommendation (SBAR) form noted a change in condition with altered mental status with agitation and psychosis. It further noted the primary care provider was notified and gave orders to send the resident to the emergency room for evaluation.

A review of the hospital record revealed the resident was admitted to the hospital on 10/27/2023.

The 10/27/2023 hospital document titled History and Physical noted that diagnoses included UTI, advanced Alzheimer’s disease, possibly end-stage, and bradycardia.

During an interview with the DON on 1/8/2024 at 12:00 pm, she stated she found out during the morning meeting on 10/23/2023 that staff were having difficulty getting the urine for the UA and Culture with Sensitivity. She stated that was when she got the urine sample from the resident. She also stated staff should have notified the physician of having difficulty getting the urine sample.