Failure to Monitor and Document Catheter Care and Urinary Output
Penalty
Summary
The facility failed to provide necessary care and services to a resident with an indwelling catheter by not following its own policies and physician orders regarding monitoring and documentation. Specifically, after the initial 30-day period of intake and output (I&O) monitoring, there was no evaluation or documentation to determine if continued I&O monitoring was needed, as required by facility policy. Additionally, the nursing staff did not consistently monitor or document findings related to bladder distention, despite this being indicated in the resident's care plan and physician orders. The resident in question had a complex medical history, including urinary tract infection (UTI), obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, and chronic respiratory failure. The care plan identified the resident as being at risk for alteration in urinary elimination and UTI due to the use of an indwelling catheter. Interventions included monitoring urine characteristics and output, observing for bladder distention, and notifying the physician of any changes. However, after the initial 30 days, there was no record of continued I&O monitoring, and staff interviews revealed that urine output was not measured or reported unless specifically done by CNAs and communicated to nurses. Documentation was also lacking regarding the assessment of bladder distention and specific signs and symptoms of UTI, even when such symptoms were present. For example, on two occasions, the presence of UTI symptoms was noted in the treatment administration record, but no specific symptoms or bladder assessments were documented in the nursing notes. The resident later experienced gross hematuria and required catheter replacement and hospitalization. Staff interviews confirmed that required assessments and documentation were not consistently performed as ordered.