Failure to Document Ordered PVR Measurements for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide appropriate treatment to prevent a urinary tract infection (UTI) for a resident with multiple complex medical conditions, including diabetes mellitus, acute kidney failure, and severe cognitive impairment. The physician had ordered post void residual (PVR) measurements every six hours for 24 hours, with instructions to re-insert a Foley catheter if the PVR exceeded 300 cc. Documentation showed that PVR measurements were recorded at three of the required times, but there was no documentation of a PVR measurement at the 6 AM interval as ordered. During an interview and record review, a registered nurse confirmed that the 6 AM PVR measurement was missing and acknowledged that it should have been charted, as the resident could have been retaining urine. The facility's policy required staff to monitor and document the resident's progress and responses to treatment. The lack of documentation for the ordered PVR measurement constituted a failure to follow physician orders and facility policy for monitoring and documenting treatment.