Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely receipt of laboratory services for a urine culture and sensitivity (C/S) test, resulting in the administration of an antibiotic that was not effective against the infection. A resident with a sacral ulcer, osteomyelitis, incontinence, impaired mobility, and severe cognitive impairment was at high risk for urinary tract infections. A urinalysis and urine C/S were obtained and sent to the lab, but only the urinalysis results were received promptly. The C/S results, which would have indicated the appropriate antibiotic, were not available to the facility in a timely manner due to issues with accessing results from the lab's software portal. As a result, the resident was started on Nitrofurantoin (Macrobid) based on the urinalysis findings, without the benefit of the C/S results. It was later discovered that the infection was resistant to Macrobid, necessitating a change to a different antibiotic (Levaquin) after the delayed C/S results were finally obtained. Interviews with staff confirmed that there were ongoing concerns with the lab's timeliness and that the C/S results should have been available within 2-3 days but were not received until nearly two weeks after collection.