Failure to Monitor Catheter Care and Urine Output
Penalty
Summary
A deficiency was identified regarding the care of a resident with an indwelling urinary catheter. The resident, who had diagnoses including Multiple Sclerosis, Spastic Hemiplegia, and the presence of urogenital implants, had a physician's order for a urinary catheter with a drainage bag. During observation, the urine bag was found to contain 50 cc of very cloudy liquid with sediment, and neither the bag nor the tubing was dated. The nurse interviewed confirmed the cloudiness of the urine and stated that the bag is sometimes changed only once a week, and that PRN staff do not always change the bags as required by facility policy. The nurse was unable to state when the urine bag was last replaced. Review of the clinical record revealed no documentation that the resident's urine output was being monitored, nor was there evidence that the physician had been notified about the cloudy urine. Additionally, there was no documentation of any monitoring or observation of the resident's status after the cloudy urine was observed. These findings indicate a failure to provide appropriate catheter care and monitoring as required.