Failure to Monitor Catheter Output and Assess Urinary Status
Penalty
Summary
The facility failed to properly assess and monitor the urinary status of a resident with an indwelling urinary catheter, resulting in urinary retention and subsequent hospitalization for a urinary tract infection (UTI). The resident, who was severely cognitively impaired and had diagnoses including chronic kidney disease, benign prostatic hyperplasia, and neuromuscular dysfunction of the bladder, had an order for catheter care and for urinary output to be recorded every shift. However, documentation showed that the last recorded catheter output was at 10:30 PM on one day, with no further documentation for approximately 13 hours prior to the resident's discharge. During this period, there was no evidence that staff assessed the catheter's patency or the resident's urinary output, despite facility policy requiring output to be recorded every shift and the collection bag to be emptied at least every eight hours. When the resident was being transferred, paramedics diverted him to the hospital due to concerning vital signs and mental status. In the emergency room, the catheter was found to be dry, and the bladder was exceptionally full, with about 1.9 liters of urine drained after catheter replacement. The ER diagnosis included UTI associated with the indwelling catheter, urinary retention, and possible acute kidney injury. Interviews with staff revealed a lack of recall regarding the resident's catheter status and inconsistent practices regarding catheter assessment and documentation. The facility's own policy emphasized the need for regular monitoring and documentation of urinary output, as well as observation for signs of infection or retention, which were not followed in this case.