Opinion ID: 2783588
Heading Depth: 3
Heading Rank: 2

Heading: Urinary Tract Infections

Text: Urinary tract infections (“UTIs”) are caused by bacteria that enter the urethra and then the bladder. Because catheter use tends to cause urinary tract infections, regulations require avoidance of catheterization if unnecessary and special care to avoid infections among catheterized residents: 45 42 C.F.R. § 483.25(c) (emphasis added). 46 Id. § 483.25(c)(1) (emphasis added). 47 Harmony Court, D.A.B. No. 1968, at 11 (2005) (emphasis added). 48 Woodland Village Nursing Ctr., D.A.B. No. 2172, at 12 (2008); Golden Living Ctr., D.A.B. No. CR2634, at 6 (2012); Edgemont Healthcare, DAB No. 2202, at 7 (2008). 18 PLOTT NURSING HOME V. BURWELL Based on the resident’s comprehensive assessment, the facility must ensure that–
an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; and
receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.49 Resident Five, a 79-year-old woman, was admitted to Plott in 2005. Her diagnoses included diabetes, hypertension, congestive heart failure, Parkinson’s Disease, urinary retention and a history of kidney stones. Her susceptibility to urinary tract infections was high for two reasons. First, she had a permanent indwelling catheter. “Urinary tract infection is one of the most common infections occurring in nursing homes and is often related to an indwelling urinary catheter.”50 The CMS guidance manual for state agency surveyors notes that “by the 30th day of catheterization, bacteriuria is nearly universal” and that individuals with catheters are 40 times more likely to have a urinary tract 49 42 C.F.R. § 483.25(d) (emphasis added). 50 SOM, supra note 8, Appendix PP Guidance to Surveyors for Long Term Care Facilities at Tag F-315. PLOTT NURSING HOME V. BURWELL 19 infection.51 She also had a history of “staghorn calculus.” Staghorn calculi are branched kidney stones in the urinary tract that increase a patient’s risk of developing a urinary tract infection. Resident Five had two staghorn calculi removed during emergency surgery on January 16, 2007 after she experienced septic shock as a result of a kidney infection. The surveyors found that Resident Five had four symptomatic urinary tract infections from December 2007 to August 2008. They cited Plott for not identifying and implementing “new approaches” to prevent the recurrent infections. The ALJ and Board affirmed this finding. This finding was not supported by substantial evidence on the record. There was no evidence that Plott did not provide “appropriate treatment and services” to avoid the infections. Plott prepared a long-term care plan in January 2007 to address the risk. The plan’s treatments included (1) monitoring for signs and symptoms of infection and reporting any noted infections; (2) ensuring daily catheter care and changes as necessary; (3) providing good perineal care; (4) encouraging fluid intake and hydration (urination flushes bacteria); (5) performing laboratory testing as ordered; and (6) administering antibiotics. When Resident Five experienced urinary tract infections, Plott prepared short-term care plans. These plans, from January 2007, February 2008, March 2008, June 2008, and August 2008, show that nurses (1) administered antibiotics to treat urinary tract infections as ordered by physicians; (2) encouraged fluid intake; (3) monitored Resident 5 for adverse symptoms; (4) reported symptoms to doctors; (5) and provided good perineal care. Similarly, the nurses’ notes show that they 51 Id. 20 PLOTT NURSING HOME V. BURWELL encouraged fluids, kept Resident Five clean and dry, and gave good perineal care. Two physicians and a nurse testified that the care provided was appropriate. The ALJ asked one physician, Plott’s medical director, what “other interventions” he could look for as he reviewed the care plans. He testified that routine interventions include good hygiene, encouraging fluids, not allowing bladder distension, getting residents out of bed to prevent backflow of urine to the kidneys, and preventing other infections. The other physician, a geriatric physician, testified that fluid intake should be maximized. The nurse testified that nurses should provide good perineal care and encourage fluid intake. The CMS guidance manual for state agency surveyors suggests the same treatments for catheterized patients that Plott provided.52 We affirmed the Board’s determination that Plott violated the bed sore regulation, 42 C.F.R. § 483.25(d), because Plott did not provide special mattresses, even though they were previously identified as required. In contrast, the Secretary has not identified any treatment that Plott should have provided to prevent Resident Five’s urinary tract infections. State surveyor nurses suggested silver coated catheters, consultations with specialists in nephrology or urology, and cranberry tablets. But the Secretary does not argue that Plott’s failure to provide cranberry tablets or a silver coated catheter violated the regulation. One of the testifying physicians stated that some patients receive cranberry tablets, but the other testified that he did not prescribe cranberry tablets, because “new evidence does not support that as a 52 SOM, supra note 8, Appendix PP Guidance to Surveyors for Long Term Care Facilities at Tag F-315. PLOTT NURSING HOME V. BURWELL 21 preventive measure.” Nobody testified about silver coated catheters or submitted any medical evidence to support their use, and nobody testified that speculative consultations were medically appropriate. There is not substantial evidence on the record as a whole to support the Board’s interpretation. The Secretary argues that, due to Plott’s lack of independently considering additional interventions beyond those recommended by her physician, Resident Five experienced recurrent urinary tract infections. But the evidence shows that her catheter and history of staghorn calculus put her at an unavoidably high risk of developing them. The regulation requires Plott to provide “appropriate treatment and services to prevent urinary tract infections,”53 not to guarantee that they will not occur. The Board held that Plott’s failure to implement new interventions violated the regulation. But, there was no evidence that Plott should have or could have done anything new that would have been “appropriate.” Though periodic reviews and revisions of care plans are required, and the surveyor faulted Plott for not revising this resident’s care plan to include cranberry tablets etc., no evidence supported her suggested revision or other revisions that might have been “appropriate.” The Board did not review her conclusion despite Plott’s putting it at issue. What we are left with, in support of the Board’s penalty, is the bed sores determination on one resident, supported by substantial evidence, the urinary tract infections on another, not supported by substantial evidence, and Plott’s history, discussed below. 53 42 C.F.R. § 483.25(d). 22 PLOTT NURSING HOME V. BURWELL