Failure to Document Foley Catheter Output per Policy and Orders
Penalty
Summary
The facility failed to monitor and document the output of Foley catheters for three residents as required by both facility policy and physician orders. The policy specified that nursing staff must assess urinary drainage for signs and symptoms of infection, including cloudiness, color, sediment, blood, odor, and the amount of urine, and document these findings every shift. Physician orders for each of the three residents also required staff to document the amount of urine output from the Foley catheter every shift. Record reviews revealed that for all three residents, there was no documentation of urine output on their Intake and Output records or Bladder reports during their respective stays. The Director of Nursing confirmed that no output was documented for these residents, despite the presence of physician orders and facility policy mandating this documentation. The lack of documentation was acknowledged as a failure to follow both the facility's catheter care policy and the specific physician orders for these residents. The residents involved had significant medical histories, including obstructive and reflux uropathy, atrial fibrillation, metabolic encephalopathy, urinary retention, congestive heart failure, benign prostatic hyperplasia, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, irritable bowel syndrome, and constipation. Despite these complex conditions and the presence of Foley catheters, the required monitoring and documentation of urinary output was not performed for any of the three residents.