Failure to Document and Monitor Catheter Care and Bladder Training
Penalty
Summary
The facility failed to ensure proper bladder training, post void residual (PVR) monitoring, and documentation after urinary catheter removal for three residents. For one resident with a history of femur fracture, stroke, and UTI, there was a lack of documentation regarding catheter clamping, resident-reported urge to void, and completion of bladder scans as ordered. Orders for bladder training and scans were inconsistently followed, and there was no consistent record of urine output or clear documentation of catheter removal and related care in the medical record. Another resident with obstructive uropathy and dementia had a physician's order for urinary output monitoring every shift, but the output was not consistently documented. The care plan required monitoring for signs and symptoms of UTI, including urine output, but the monitoring log showed multiple days without any recorded output, and only sporadic entries were made. A third resident with a groin abscess and an indwelling catheter also had inconsistent documentation of urinary output, with several days missing entries and only a few outputs recorded. The facility's catheter care policy required drainage bag emptying and output documentation at the end of each shift, but this was not followed. The Director of Nursing confirmed the lack of documentation for catheter care, bladder training, and urine output, as well as inconsistencies in following physician orders and facility policies.