Failure to Accurately Record Catheter Urine Output
Penalty
Summary
The facility failed to ensure accurate recording of catheter urine output for a resident with an indwelling urinary catheter. The resident had multiple diagnoses, including sepsis, infection and inflammatory reaction due to the catheter, bacteremia, hematuria, obstructive and reflux uropathy, and urinary retention. Physician orders required the monitoring of catheter output three times daily, and the resident was also receiving diuretic medication for edema. However, documentation from the facility showed that staff recorded urine output using qualitative terms such as 'small,' 'medium,' or 'large' instead of measuring and recording the exact amount in milliliters as required by both physician orders and facility policy. Interviews with staff confirmed that the expected practice was to use a calibrated measuring container to determine the precise urine output and document the amount in the medical record. Facility policies on emptying urinary bags and catheter care also specified the need for accurate measurement and recording of urine output. Despite these requirements, the medical record for the resident consistently lacked quantitative measurements, leading to a deficiency in the standard of care provided.