Inaccurate Documentation of Urinary Output for Absent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one resident regarding urinary output. The resident, who had multiple diagnoses including muscle weakness, mobility issues, and both acute and chronic respiratory failure, was admitted with an indwelling catheter and an order for routine catheter care. Despite being transferred to the hospital and not present in the facility, the resident's Treatment Administration Record (TAR) showed documented catheter outputs for days when the resident was not in the facility. Interviews with staff revealed uncertainty about documentation procedures when a resident is out of the facility. The LPN was unsure if outputs should be recorded during a resident's absence, while the CNA stated that output documentation is only done when the resident is present. The DON confirmed that documentation of outputs should not occur when a resident is not in the facility and verified that incorrect entries were made in the resident's record. Facility policy requires maintaining an accurate record of daily output, which was not followed in this instance.