Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to obtain and document urinary outputs as ordered for a resident with an indwelling urinary catheter. The resident, who had diagnoses including bladder-neck obstruction and obstructive and reflux uropathy, was admitted with a physician's order to record catheter output every shift. The resident's care plan also directed staff to monitor output every shift and observe for signs and symptoms of urinary tract infections. However, review of the Treatment Administration Records (TARs) over several months revealed multiple instances where urinary output was not obtained or documented across various shifts. Additionally, nursing progress notes did not contain documentation for the missing output amounts. Interviews with staff indicated that CNAs were responsible for emptying the catheter bag, measuring urinary output, and reporting it to the nurse, who was then responsible for documenting the output on the TAR. The process relied on verbal or written communication (such as sticky notes) from CNAs to nurses, with no specific form or direct CNA charting of the output. The Director of Nursing confirmed that the facility's goal was to have all charting completed, and acknowledged that if documentation was missing, it was considered not done. The facility's policy required tracking of output for all residents with indwelling catheters, but did not provide specific guidance on obtaining and documenting urinary output.