Failure to Monitor and Document Urinary Catheter Output as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, as required by professional standards and the resident's physician order. The resident, who had diagnoses including end stage renal disease, hydronephrosis, urinary retention, and diabetes mellitus, was dependent on staff for all activities of daily living and had a physician order to monitor urinary output every shift. The care plan also indicated the need to monitor intake and output every shift due to the resident's risk for urinary tract infection (UTI). However, interviews and record reviews revealed that the resident's urinary catheter bag was not being emptied and measured every shift as ordered. The resident reported that the bag was only emptied in the mornings and afternoons, and documentation of urinary output was missing for multiple shifts across several days. Staff interviews confirmed that the resident's urinary output should have been monitored, emptied, and measured once per shift, and that this was important for assessing urinary retention and preventing complications. The Medication Administration Record (MAR) lacked documentation of urine output in milliliters for several shifts, and both nursing and supervisory staff acknowledged the importance of this monitoring for a resident on dialysis with an indwelling catheter. The facility's policy required recording intake and output for residents with indwelling catheters or when ordered by a physician, but this was not consistently followed for the resident in question.