The Illinois Department of Health has cited and fined Sunny Acres Nursing Home when nursing staff repeatedly failed to properly monitor, document, or seek treatment for a resident with urinary catheter problems showing clear signs of infection. The resident ultimately had to be hospitalized for intravenous antibiotics to treat a serious urinary tract infection and encephalopathy, a potentially life-threatening brain condition.
The resident in question had an indwelling urinary catheter, which is a tube inserted into the bladder to drain urine. Nursing notes initially documented that the resident’s urine was “dark and slimy with a foul odor,” and the Medical Director ordered a urinalysis. The urinalysis results came back positive for a urinary tract infection (UTI) caused by ESBL and E. coli bacteria, which are particularly concerning infections because they can be resistant to many antibiotics.
After this positive test result, nursing staff failed to document any physician notification or follow-up care plan. More concerning, the facility’s records showed the resident had no urine output for multiple shifts over several days. On one day, both overnight and day shifts documented zero urine output. On another day, third shift and day shift documented the resident’s urine output as zero, with no documentation for the evening shift.
A Certified Nursing Assistant (CNA) reported coming to work and noticing “the resident had no urine in her indwelling catheter bag.” The CNA properly reported this to a Registered Nurse, along with concerning observations that the resident “was throwing up in dining room and was more confused.” The CNA also noticed “brown urine in the resident’s depend [adult diaper], but not in the resident’s indwelling catheter bag.”
The nurse attempted to irrigate (flush) the catheter but was unsuccessful. Nursing notes later documented, “Resident complains of pain at the indwelling urinary catheter site, brown mucus discharge coming from vagina. Resident hasn’t voided in two days per CNA and documentation.” Only at this point was the Medical Director notified, who ordered the catheter removed and the resident sent to the emergency room.
At the emergency room, hospital staff placed a new catheter, which drained “dark gold urine.” The emergency room physician documented that the resident’s condition “could potentially be life threatening or risk to bodily function.” The resident was diagnosed with a UTI due to urinary retention, with evidence of cystitis (bladder inflammation) and hydronephrosis (kidney swelling due to urine backup).
After returning to the facility with antibiotics, the pattern of poor monitoring continued. Records showed multiple shifts with either no documentation of urine output or documented concerning low outputs (as little as 15 milliliters in an entire shift). Despite these red flags, there was no documentation of physician notification until several days later.
When the physician was finally notified of continued issues, she ordered another urinalysis. However, even after receiving this order, the nursing staff failed to collect the specimen promptly. One nurse admitted she “didn’t have time” to collect the sample and passed the task to the next shift. Another nurse collected the sample but left it in the refrigerator. The urinalysis wasn’t actually performed until several days after it was ordered.
When finally collected, the resident’s urine was described as “green, thick, and has a foul odor,” at which point the resident was sent back to the hospital. Hospital records show the resident was admitted for intravenous antibiotics to treat both the UTI and encephalopathy, a brain condition that can be caused by infection and may be life-threatening if left untreated.
Even after this second hospitalization, the pattern of poor monitoring continued, with more documented instances of low or absent urine output without proper physician notification.
The Medical Director stated she “would expect the facility to call and notify if a resident with a catheter has not voided in an eight-hour shift.” She confirmed that neither her office nor her personal cell phone received any calls about the missing antibiotic orders or the resident’s lack of urination. She emphasized that the resident “could have become very sick because of the facility not notifying of absent or low urine output” and could have developed sepsis, a life-threatening complication of infection.
The Director of Nursing admitted multiple documentation failures, stating “I tell the staff all the time to document it, or it didn’t happen.” When questioned about the delayed urinalysis collection, she stated that it “should have been collected the same day it was ordered” and admitted she “was not aware the resident’s medical chart had days with absent or decreased urinary output.”
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
