Failure to Document Urinary Catheter Output as Ordered
Penalty
Summary
The facility failed to ensure that urinary output was consistently monitored and documented for two residents with indwelling urinary catheters. For one resident with cognitive impairment and a diagnosis of benign prostatic hyperplasia, the care plan and physician's orders required staff to measure and document urinary catheter output every shift. However, clinical record reviews revealed multiple instances across various shifts where there was no documented evidence of urinary output being recorded, as confirmed by the Director of Nursing. Similarly, another resident with a neurogenic bladder and an indwelling catheter had physician's orders and a care plan directing staff to document urinary output every shift. Review of this resident's records also showed missing documentation of catheter output on several shifts, which was acknowledged by the Director of Nursing. These findings indicate that the facility did not follow physician orders and care plan interventions for monitoring and documenting urinary output for residents with indwelling catheters.