Failure to Monitor and Document Catheter Output for High-Risk Resident
Penalty
Summary
The facility failed to consistently monitor and document urine output for a resident with a suprapubic catheter who was at risk for urinary tract infections. The resident, who had diagnoses including neurogenic bladder, paraplegia, and adult failure to thrive, was totally dependent on staff for care and had a physician order requiring staff to record catheter output per shift and monitor for signs and symptoms of infection. Despite this, review of the Medication and Treatment Administration Records showed that urine output was only documented once on three separate days in June, and there was no documentation of urine output from June 24th to June 30th. Additionally, the Point of Care Response History lacked documentation of urine output for a full week in July. Staff interviews revealed inconsistent practices regarding urine output monitoring, with a nurse consultant stating that output was not monitored on all catheters unless there was a physician order or the resident was considered high risk, despite the presence of such an order for this resident. The resident had previously been admitted to the hospital with septic shock, and facility policy and nursing references indicated the importance of monitoring urine output and promptly reporting abnormal changes. The lack of consistent monitoring and documentation represented a failure to follow physician orders and established care protocols for residents with urinary catheters.