Failure to Monitor and Document Urinary Output
Penalty
Summary
The facility failed to provide necessary and appropriate care and services to prevent complications for several residents, including Resident #1, who had a diagnosis of prostatic hyperplasia. The facility did not adequately monitor and document the urinary output of Resident #1, leading to a situation where the resident had no output for an extended period. Despite a physician's order to change the catheter monthly and as needed, there was a lack of documentation regarding the size of the re-inserted catheter, observation of flow, or how the resident tolerated the procedure. The staff failed to communicate effectively about the resident's condition, resulting in a delay in sending the resident to the emergency room. Resident #1 experienced a critical situation where clots were present, and there was no urinary output for more than eight hours. The APRN was informed late about the resident's condition, and the order to send the resident to the ER was not transcribed promptly. The resident was eventually sent to the hospital after being found unresponsive, with symptoms including a high temperature, rapid breathing, and low oxygen saturation. The facility's documentation and communication failures contributed to the delay in addressing the resident's urgent medical needs. Additionally, the facility failed to monitor and document the urinary output for other residents, including Residents #4, #5, #8, and #61, as per physician orders. The Director of Nursing was unaware of these lapses in monitoring, indicating a systemic issue in the facility's adherence to care plans and physician orders. The lack of documentation and timely intervention highlights significant deficiencies in the facility's care and monitoring processes.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: > Resident #1 no longer resides in the facility. > Residents #4, #5, #8, & #61 had an RN assessment completed. > Resident #999 was provided with care at the time of grievance. 2) How you will identify other residents: > Securement device, care Qshift, and to record the output Qshift. > The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A.B.C. & D. > The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. > The facility's Staff Development Coordinator/Designee completed education with CNAs on completing the required ADL documentation. > The facility's Staff Development Coordinator/Designee completed education with Nurse Unit Managers and RN Weekend Supervisor on monitoring the completion of ADL documentation. System Change: > Output was added to the MAR to ensure nursing documentation. > CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. > The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. > The facility implemented staff huddles led by Nurse Unit Managers to address ADL documentation completion. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: > The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. > The facility initiated the completion of audits seven days a week including output documentation for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. > The daily clinical meeting form was edited to include: > - Review of 24-hour report for change in condition. > - The review of vital signs and the timely transfer of all residents that returned to the hospital. > - The review of all new admissions and existing residents with output to ensure orders to monitor are in place. > - The review of vital signs and the review of the nurses' change of condition evaluation for all residents that had a change in condition. > - The review of vital signs for all residents per physician order. > - The review of PCC ADL Documentation.