Failure to Monitor and Document Indwelling Catheter Care
Penalty
Summary
The facility failed to properly monitor and document the use and function of indwelling urinary catheters for two residents with complex urinary needs. Both residents had physician orders and care plans requiring staff to measure and record urinary output every shift, as well as to monitor for signs and symptoms of catheter-associated complications. However, review of treatment administration records (TARs) revealed numerous missed opportunities for documentation of urinary output, with 21 out of 62 entries missing for both residents in March, and additional missed entries in April. There were also multiple instances where urinary output was recorded as less than 30ml per hour, but no corresponding nursing assessments or notifications to medical providers were documented in the progress notes. For one resident with a neurogenic bladder and a history of urinary tract infections (UTIs), the lack of monitoring and response to low urinary output led to a situation where the resident experienced a distended abdomen, pressure, and leaking catheter, which was only addressed after a significant delay. The catheter was eventually replaced, resulting in immediate relief and drainage of a large volume of urine. The resident later reported that staff did not respond promptly to their concerns and that they were diagnosed with a UTI upon hospital admission. Interviews with staff confirmed that documentation was inconsistent, particularly among agency staff, and that there was confusion regarding which residents required output monitoring. The second resident, admitted with obstructive uropathy and also requiring an indwelling catheter, experienced similar lapses in care. Documentation of urinary output was frequently missing, and low output readings were not followed up with assessments or provider notifications. Progress notes failed to address these changes in condition, and staff interviews confirmed awareness of ongoing issues with monitoring and recording urinary outputs for residents with specific orders. The facility's policy required appropriate catheter care and monitoring, but these standards were not consistently met for the residents reviewed.