Failure to Document Urinary Output and Incontinent Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for a resident with an indwelling urinary catheter. According to the facility's policy, urine output was to be documented in the resident's chart or electronic medical record. However, review of the clinical records for a resident with neurogenic bladder and a physician's order for a Foley catheter revealed multiple instances across several dates and shifts where urine output was not recorded as required. This lack of documentation was confirmed by the Director of Nursing. Additionally, the facility did not ensure that proper incontinent care was completed for another resident who required assistance with toileting due to limited mobility. The care plan specified that staff should document the resident's bladder continence or incontinence every two hours, but there were numerous occasions where this documentation was missing. Furthermore, staff were required to document the application of barrier cream to the resident's buttocks, but there was no evidence that this was done on several shifts across multiple days. These deficiencies were identified through review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the absence of required documentation for both urinary output and incontinent care, including the application of barrier cream, on the specified dates and times.
Plan Of Correction
Resident 1 was assessed with no ill effects and/or noted concerns related to her not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The documentation was also missing on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 1's physician was notified of the resident not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The physician was also notified of missing documentation on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 13 was assessed with no ill effects and/or noted concerns related to her not having her bladder continence/incontinence documented on May 14, 2025, at 0800, 1000, and 1200; May 15, 2025, at 0800, 1000, and 1200; May 17, 2025, at 0800, 1000, and 1200; May 24, 2025, at 0800, 1000, and 1200; May 25, 2025, at 0000, 0200, and 0400; June 4, 2025, at 0000, 0200, and 0400; June 5, 2025, at 0000, 0200, and 0400; June 6, 2025, at 0800, 1000, and 1200; June 10, 2025, at 0800, 1000, and 1200; June 11, 2025, at 0800, 1000, and 1200; June 13, 2025, at 0000, 0200, and 0400; June 15, 2025, at 0800, 1000, 1200, 1400, 1600, 1800, and 2000; and June 25, 2025, at 0800, 1000, and 1200. The physician was notified of the missing documentation of bladder continence/incontinence for Resident 13 on the same dates and times as above. Resident 13 was also assessed with no ill effects and/or noted concerns related to her not having any documented evidence of her barrier cream being applied to her buttocks during the day shift on May 1, 2025; May 15, 2025; May 17, 2025; May 24, 2025; and May 26, 2025. The documentation was missing during the evening shift on May 1, 2025; May 2, 2025; June 3, 2025; and June 15, 2025, and during the night shift on May 24, 2025; May 31, 2025; June 2, 2025; June 3, 2025; June 4, 2025; and June 12, 2025. The physician was notified of the missing documentation of barrier cream application to Resident 13’s buttocks during these shifts and dates. Any resident who has an indwelling urinary catheter has the potential to be affected by this alleged deficient practice. A whole house audit of residents with indwelling urinary catheters was completed to ensure their urinary output has been monitored and documented in the resident's medical record/electronic medical record every shift. Similarly, any resident who has a nurse aide task to document bladder continence/incontinence every two hours has the potential to be affected. A whole house audit of residents with this scheduled task was completed to ensure documentation of bladder continence/incontinence has been monitored and recorded in the medical record/electronic medical record every two hours. Any resident with a nurse aide task to document application of barrier cream also could be affected. A whole house audit of residents with this task was completed to ensure documentation of barrier cream application was present in the Point Click Care - Point of Care electronic record. Direct care staff, including agency staff, were re-educated on the facility's Urinary Output Policy, emphasizing the importance of monitoring and documenting urinary output every shift for residents with indwelling urinary catheters. Staff were also re-educated on the importance of frequently monitoring residents' bladder continence/incontinence throughout the shift and documenting in Point Click Care as scheduled, including every two hours. Additionally, staff were re-educated on the importance of applying barrier cream to residents and documenting the application in the electronic medical record/Point Click Care as per scheduled tasks. The Director of Nursing/designee will audit the documentation of urinary output for residents with indwelling urinary catheters weekly for fifteen weeks, then monthly for six months, and review the results with the Quality Assurance Performance Improvement Committee for areas of improvement and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings for ten months or until substantial compliance is noted. Similarly, the Director of Nursing/designee will conduct random audits of Point Click Care - Point of Care task documentation for bladder continence/incontinence weekly for fifteen weeks, then monthly for six months, with results reviewed by the committee. The same process applies for audits of resident barrier cream applications, with results reviewed in the same manner.