Failure to Notify Physician and Document Urostomy Care
Penalty
Summary
A deficiency occurred when a resident with a urostomy did not receive care consistent with professional standards, the care plan, and physician orders. The resident, who had multiple complex diagnoses including multiple sclerosis, bladder cancer, and a history of acute pyelonephritis, was observed to have cloudy urine with white sediments in the urinary tubing. Despite this, staff failed to notify the physician of these abnormal findings, as required by both the resident's care plan and facility policy. Certified Nursing Assistant (CNA) observed the cloudy urine but did not report it to the Licensed Vocational Nurse (LVN), and the LVN only became aware of the issue after being informed later. The Director of Nursing (DON) and other staff confirmed that the physician should have been notified immediately about the abnormal urine appearance. Additionally, the facility failed to assess, monitor, and document the resident for signs of urinary tract infection (UTI) as indicated in the care plan. The care plan specifically required monitoring for symptoms such as pain, burning, blood-tinged urine, cloudiness, changes in urine output, and other signs of infection. However, review of the resident's progress notes and other documentation revealed that there was no consistent monitoring or documentation of these signs and symptoms. The Director of Staff Development (DSD) acknowledged that nurses did not document assessments of urine color, odor, or presence of sediments every shift, as required by policy. Furthermore, the facility did not follow the physician's order to monitor and document the resident's urine output in milliliters (ml) every shift. Instead, documentation in the Medication Administration Record (MAR) only indicated the number of times the resident urinated, not the actual volume, which was contrary to the physician's explicit instructions. The DSD and DON both confirmed that this failure to document urine output in ml could result in unrecognized urine retention. Facility policy also required accurate measurement and documentation of input and output, which was not followed in this case.
Plan Of Correction
F 691 F 691a. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On 4/30/25, LVN 1 immediately called MD to notify him of Resident 1 urinary tubing sediments and cloudy urine. ADON placed an order in PCC for monitoring of foley catheter output for Resident 1 on 05/01/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents with foley catheter on 4/30/25 and noted no change of condition indicated, therefore, no notification to MD was required. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25 F 691 F 691. b&c How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice DON performed one-to-one in-service to LVN 1 on 4/30/25 regarding proper documentation of monitoring urine output in milliliters as well as documentation and proper assessment of the quality of the output. DON also reviewed the importance of following physician order. DON also reviewed facility policy and procedure "Urinary Catheter Care" with LVN 1 on 4/30/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents in the facility with foley catheter on 4/30/25 and found no other signs of UTI related to catheter care. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25